An internal Oranga Tamariki review found a series of failures in the agency's handling of a baby before he was killed by his father, RNZ can reveal.
By Sam Sherwood of RNZ
Mustafa Ali was hospitalised about eight months before his death with serious injuries that his father said were caused when he fell while carrying him down some stairs.
A review found several failings in the agency's response after Mustafa was injured, including "minimal analysis" of risk and no documented analysis of medical evidence against the family's explanation for his injuries. It also said the monitoring by a social worker was not good enough.
Mukzameel Ali was jailed for six years in the High Court at Hamilton in May by Justice Layne Harvey after pleading guilty to the manslaughter of his nine-and-a-half month old son Mustafa Ali.
Oranga Tamariki earlier confirmed to RNZ that a review was carried out by the Office of the Chief Social Worker which found there were aspects of its involvement that "did not fully meet our expected standards of practice".
RNZ has since obtained a summary of the Rapid Practice Assessment under the Official Information Act.
The summary says a health staff member sent a report of concern to Oranga Tamariki about unexplained injuries to Mustafa in October 2023.
Mukzameel Ali earlier told this reporter, while working at Stuff, that there had been an incident where while holding Mustafa he had fallen down some stairs. He said Mustafa suffered a collarbone fracture, fractured ribs as well as bleeding on his head.
Oranga Tamariki social workers completed a Safety and Risk screen.
"As there were concerns about Mustafa's ongoing safety a family meeting, to agree a safety plan, was held.
"It was agreed that when Mustafa was discharged from hospital he would be cared for by his Grandparents."
In late October 2023, Mustafa was discharged from Waikato Hospital into the care of his grandparents. At a family meeting on November 3, it was agreed that Mustafa would remain with his grandparents until a Family Group Conference (FGC) was held.
The FGC took place in February 2024. The summary said the goal was for Mustafa to return to his parents' care in "staged manner, with ongoing support from grandparents". Mustafa was fully in his parents' care by early March.
A second FGC was held in May where a support plan involving Oranga Tamariki, community agencies and extended family was agreed.
In early June, Oranga Tamariki staff visited the family home. Mustafa died on June 8.
'Key processes, oversight and approval steps were missed'
The summary said actions taken initially in response to Mustafa's first injuries were appropriate.
"Following Mustafa's first admission to hospital, the Multi-Agency Safety Plan and the subsequent family meeting plan dated November 3, 2023 were thoroughly recorded and adequately addressed Mustafa's initial safety following his discharge home."
It also said there was "clear evidence" of working with Police under the Child Protection Protocol (CPP). However there were opportunities to work more closely with the Police and Health "at key decision points".
"While Health was not a partner in the CPP, inviting Health to CPP consultations with Police about Mustafa to explain medical information about his injuries could have provided an opportunity to develop a more holistic understanding of the safety risks and wellbeing needs of Mustafa."
A 22-year-old man has appeared in court this morning charged with the murder of 10-month-old Mustafa Ali in Te Kūiti last week. (Source: 1News)
The review also said the assessment contained "minimal analysis of the strengths, risks and needs of either side of the family or an understanding of Mustafa in context of his cultural identity".
"The review did not find any evidence of the analysis of presenting concerns and early medical opinion alongside the subsequent explanation by family that Mustafa's injuries were caused accidentally.
"Similarly, the review team did not find evidence of the analysis and decision to continue the transition home once the full Medical Assessment Report was received."
It also found neither of the FGC plans contained clear statements about the concerns to be addressed, they also did not provide specific "time-framed actions" to address the concerns.
"Whilst there was involvement by other agencies in supporting Mustafa and his family, the agreed monitoring arrangements that saw the social worker visiting 'from time to time' were not sufficiently specific nor robust enough in light of the serious injuries he had received and wider known parenting concerns."
The review said assessment was "an ongoing process that needs to be regularly revisited".
"The review team found that at three critical points - the sign off into intervention, FGC referral, and pre-FGC planning - there was no updated and approved assessment report."
Safety plans were not reviewed, which meant that the plans were "not flexible enough to respond to significant events and changing circumstances".
"It was not clear how the effectiveness of interventions to build safety and mitigate risk were being measured once Mustafa had returned to his parents' care."
There was also no supervision case decision-making records in the Care and Protection, Youth Justice, Residences, Adoptions System (CYRAS) in relation to the social work practice with Mustafa.
"It is noted that ad hoc, informal supervision for the kaimahi occurred as requested but did not occur at critical decision-making points in the casework."
Mustafa was also not included on the Vulnerable Unborn/Newborn register prior or after his birth.
"This is inconsistent with expected practice which provides for additional monitoring of reports of concern regarding babies given their increased vulnerability."
The review also identified concerns about staff capability.
Oranga Tamariki staff reported there was a "lack of basic knowledge of practice and legislation" among some of the social workers and supervisors on site.
"The review team did not find evidence that the intervention approach and safety plans reflected core knowledge and understanding of dynamics of abuse, risk, and 'what works' to prevent future abuse.
"The review team was told that social workers at the site did not always have regular supervision with their Oranga Tamariki supervisor."
OT responds
Oranga Tamariki deputy chief executive of tamariki and whānau services Thomas Ronan earlier said the baby's death was "devastating".
"Oranga Tamariki had a safety plan in place.
"More should have been done to ensure our plan was working."
Ronan said the social worker involved was no longer employed by Oranga Tamariki.
"Our site office has strengthened its practice through additional training and targeted support."
Ronan said a number of changes had since been made at Oranga Tamariki including ongoing training on child protection protocols, and upskilling in other areas for staff who require it.
They had also strengthened professional supervision for staff and increased oversight of cases.
Ronan said Oranga Tamariki has also introduced new assessment and planning tools to support social work decision making alongside families and increased "collaborative ways of working across agencies and within communities to keep children safe".
Ronan said the department's thoughts remained with Mustafa's family.
Chief Victims Advisor Ruth Money said in a statement to RNZ she was "absolutely devastated" when she read the review.
"In many ways issues identified here were mentioned in the multiple reviews undertaken when Malachi Subecz was killed.
"Reviews at that time identified serious practice and organisational failures. Weak supervision coupled with practice that is well below expected professional standards are yet again identified in this, the most recent review regarding the tragic and preventable death of Mustafa Ali.
"We owe it to all children and whanau to urgently and significantly improve practice with respect to culturally appropriate safeguarding and child protection."
She urged management at Oranga Tamariki to act with "meaningful and sustainable action", and looked forward to discussing it with them when they meet later this month.
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