Oranga Tamariki has apologised and is making immediate changes to ensure greater scrutiny on how children are taken into care.
It has released the findings of its review into the controversial uplift of a baby from Hastings Hospital.
- Oranga Tamariki: 'Listening posts' for families to detail their social work experiences launched as part of inquiry
- Māori 'at war' with Oranga Tamariki
The findings suggest although Oranga Tamariki did the right thing to get involved, mistakes were made.
"I know we have hurt this whānau - and I am truly sorry," chief executive Grainne Moss said.
"Our work here wasn't of a high standard and our usual checks and balances also failed."
While there were safety concerns for the baby, Moss said Oranga Tamariki did not do a good job in this particular case.
"All of the recommendations of the review have been accepted."
- Oranga Tamariki: Māori leaders issue strong call to action over uplifts
- Oranga Tamariki Minister Tracey Martin admits Hawke's Bay attempted uplift wasn't 'well done'
As a result of the review, Oranga Tamariki has made the following changes:
- Unless there is a clear need for action to protect a child from immediate and imminent danger, all interim custody order applications will be made 'on notice' to ensure the family is given the opportunity to have their say before a judge makes a final decision.
- When staff need to act faster to keep a child safe, every Section 78 'without notice' application will go through additional checks with a Regional Legal Manager, a Site Manager and a Practice Leader all signing off.
- Additional investment will be made into staff training nationwide and greater supervision for Family Group Conferences
- Practise leaders on every site will look at all reports of concern for unborn and newborn babies and check that we put the right planning and assessment around vulnerable mothers at the earliest opportunity.
- In Hastings, more resources and training will be provided to staff and a new Regional Supervisor appointed.
The Children's Commissioner has acknowledged the family at the centre of the "tragic" situation.
Andrew Becroft said the family of the baby, particularly the mother, had been "incredibly strong".
"Clearly, they have experienced significant trauma from this process."
Becroft said the released review is "rigorous and robust".
"However, it describes a litany of failure at every step. It is a damning indictment of inadequate social work practice.
"It's important that the lessons learned from this case are used to bring about systemic changes, as it is unlikely this is an isolated incident.
"Recommendations in the report must be completed with urgency."