An investigation into Oranga Tamariki's handling of the case of 5-year-old Malachi Subecz in Tauranga, who was murdered by his caregiver, has found the agency failed to take the "bare minimum" action over fears for the child's safety.
The report into Oranga Tamariki's handling of the case was released on Wednesday by Chief Ombudsman Peter Boshier. It found the children's agency's response was "a litany of failures" and did not prioritise Malachi's welfare.
Malachi died in Auckland's Starship Hospital in November after being found with injuries a Judge said were obtained through abuse considered no less than torture.
The carer who murdered Malachi, 27-year-old Michaela Barriball, was jailed for at least 17 years in June.
Malachi had been placed in the care of Barriball by his imprisoned mother.
Boshier undertook an investigation into Oranga Tamariki's handling of the case after Malachi's uncle and cousin complained to him about the agency's actions, he said.
The Chief Ombudsman said Malachi's cousin first reported concerns about his welfare to Oranga Tamariki in June last year - including medical neglect and proof of suspected physical abuse.
"If an investigation is begun, Oranga Tamariki is required to do an assessment followed by a safety and risk screen - the screen identifies whether immediate action is required to secure the safety of the child."
However, Boshier said those steps weren't taken to ensure Malachi's safety and, despite his cousin providing a photo of the child with a suspected bruised eye, Oranga Tamariki did not report it to the police as is required.
"There is no record that Oranga Tamariki considered its obligations under the CPP (child protection protocol) at any stage, nor did it record any consideration of the suspected bruising."
Boshier said Oranga Tamariki spoke to Malachi's mother in prison, who had no concerns and the agency took no further action. That decision was wrong, he said.
"Malachi's welfare and interests were not prioritised; they were instead wrongly assumed to be addressed or overridden by his mother's endorsement of his carer, in spite of evidence that he may not be safe."
Boshier also discovered there was no evidence Oranga Tamariki carried out a safety check of the carer's home, nor anyone meet with Malachi to find out how he felt about being there.
"It is my view that Oranga Tamariki omitted to do all that was necessary and desirable and it should have investigated the report of concern," he said.
"Oranga Tamariki's response to Malachi's cousin's report of concern does not appear to have fulfilled the bare minimum of the process required to ensure Malachi's safety."
The agency, overall, acted "unreasonably and wrong", Boshier said.
Boshier added Oranga Tamariki should apologise to Malachi's whānau in a way that was right for them.
"The apologies should recognise the impact of Oranga Tamariki's actions," he said.
Boshier said Oranga Tamariki had accepted his findings. He said he'd be closely monitoring two other independent reviews into the case currently underway.
"I believe my findings will help inform these reviews. The objective must be to prevent such tragedies from happening again."
He said he wanted Oranga Tamariki to get in contact with him once those reviews were complete.
"I want Oranga Tamariki to report to me once those reviews are completed and explain how they will influence its policy, practice and guidance. I may make further recommendations or undertake a further investigation if I am not satisfied with its response."