Source: Waatea News.
The release of the Coroner’s findings into the death of Malachai Subecz has reopened deep wounds across Aotearoa, with many describing the tragedy as preventable and avoidable.
Malachai’s death triggered practice reviews by six government agencies that had contact with him, his mother Jasmine, or his caregiver Michaela. Those agencies were New Zealand Police, the Department of Corrections, Oranga Tamariki, the Ministry of Social Development, the Ministry of Education and the Ministry of Health.
Each agency examined its own actions and decisions. However, the Chief Executives of the six agencies also jointly commissioned an independent review led by Dame Karen Poutasi to take a whole-of-system approach to understanding what went wrong.
Her report identified critical structural failures in how the children’s sector identifies and responds to abuse.
Dame Poutasi concluded that Malachai became an invisible child within the system.
She identified five major gaps:
- Failure to properly identify the needs of dependent children when sole parents are charged and prosecuted.
- A risk assessment process that was too narrow and one-dimensional.
- A lack of proactive information sharing between agencies despite enabling provisions.
- Failure by some professionals and services to report suspected abuse.
- System settings that enabled a vulnerable child to be unseen at key moments.
She also identified at least 33 previous reviews over the past 30 years examining child abuse and child deaths, with recurring themes of siloed responses, weak follow-up of reported concerns, poor information sharing and inadequate training.
The Department of Corrections review found extensive monitored communications between Jasmine and Michaela while Jasmine was in prison, but those calls were not monitored in real time and were only reviewed after Malachai’s death.
The Oranga Tamariki review identified failures to escalate a report of concern into a comprehensive assessment. A visit to Malachai was never carried out. Later concerns were not revisited, and workload pressures were noted as influencing decision-making pathways.
The Chief Ombudsman later found that Oranga Tamariki failed to meet the minimum requirements to ensure Malachai’s safety and acted unreasonably in addressing the report of concern.
The Ministry of Health review found Malachai had routine access to health care, but identified weaknesses in information sharing across sectors and the absence of a Gateway Assessment, which is currently triggered only when a child formally enters care.
The Ministry of Education cancelled the daycare centre’s licence after finding it failed to follow its own child protection policies when injuries were noticed.
In addition to existing reviews and recommendations, the Coroner has now issued further comments and recommendations under section 57A of the Coroners Act aimed at reducing the likelihood of similar deaths in the future.
The Coroner made clear that these recommendations are not intended to duplicate prior findings, but to focus on practical and targeted changes that could and should be implemented alongside the recommendations of Dame Poutasi, the Chief Ombudsman, the Independent Children’s Monitor and the individual agency reviews.
The findings emphasise that Malachai’s death must be viewed in the broader context of repeated child abuse tragedies in New Zealand. The Coroner noted that similar themes and recommendations have appeared year after year with limited evidence of substantive system-wide change.
The message is stark: urgent action is required.
The recommendations call for policy and practice changes, but also for systemic accountability and monitoring to ensure reforms are not merely announced but embedded.
Since Malachai’s death, a judiciary-led cross-agency working group has introduced new court processes to ensure the existence of dependent children is consistently identified when a primary caregiver faces imprisonment.
The changes are designed to prevent children from becoming invisible during criminal proceedings and to ensure their welfare is considered early in bail and sentencing decisions.
The Coroner’s findings underscore a deeply troubling pattern. For decades, inquiries into child deaths have identified the same systemic weaknesses: agencies working in isolation, failure to share information, insufficient follow-up, and an inability to verify the lived reality of vulnerable children.
Malachai’s case reflects not a single point of failure, but a network of missed opportunities.
The question now confronting Aotearoa is whether this tragedy will lead to sustained, structural reform – or whether it will join the long list of previous reviews documenting failures that were acknowledged but not fully resolved.
The Coroner’s warning is clear: without decisive action, children will continue to slip through the gaps.
For many New Zealanders, the test is no longer whether recommendations will be made.
It is whether they will finally be implemented.
Author
Waatea Team
Radio Waatea is Auckland’s only Māori radio station that provides an extensive bi-lingual broadcast to its listeners. Based at Ngā Whare Waatea marae in Māngere, it is located in the middle of the biggest Māori population in Aotearoa.
