Malachi Subecz was not in State care but reports of concern had been made about him. Six government agencies completed reviews of their own processes, and chief executives also commissioned a system-wide review from Dame Karen Poutasi (the Poutasi review). The Poutasi review referred to there being those who tried to act but were not listened to, those who were uncertain but did not act, and those who knew but chose not to act.

This report looks at whether the recommendations made by the Poutasi review have been actioned. It also looks at whether the actions arising from the individual agencies’ own reviews have been completed and whether tamariki (children) are safer as a result. It found that tamariki are no safer now than when Malachi died.