A Child Youth and Family manager admits the agency failed multiple times when it sent a Southland toddler back into a P-using household where he died.
A secret recording of these admissions, made in a meeting with the 17-month-old's extended family, has been given to RNZ by the family.
Child Youth and Family told RNZ that publicising the recording would "impede our ability to do our job of keeping children and young people safe".
The agency is worried if RNZ broadcasts any part of the recording, it will undermine public trust in CYF and make it more difficult to have free and frank discussions.
The family on the father's side says just the opposite - that the public need to know just how badly wrong the agency got this case, so that it's forced to change.
The family praised the CYF manager who did the internal review for having the guts to front up to them - but in the end say the recording of their two-hour meeting with her and a colleague last September showed an agency failing in the most basic way.
"We felt that CYFs were paying lip service to our family," said the toddler's aunt, the sister to his father.
"They knew that we were going to keep asking tough questions, and that they engaged with our family at this point, because they knew we were not going to go away. And we certainly felt like they were just there to tick a box."
The boy died in October 2015 and the mother's boyfriend was found dead in prison five weeks later, after pleading not guilty to murdering him. All names are permanently suppressed.
Ability of mother to protect children not assessed
In the meeting, the CYF manager told the family more than once that no one could have predicted what would happen, and on three occasions she said social workers did not have crystal balls or magical predictive powers.
However, she then went on to detail a litany of things it didn't do, or did badly.
The manager said CYF did not assess the ability of the toddler's mother to protect her two children.
This omission became crucial when a district court judge asked the agency to assess the risks if the boyfriend went back to live with the children.
He was on bail for various charges including violence charges. These had been laid in May 2015, within three months of him getting together with the mother. The Corrections Department and police opposed a change to allow him back at the house.
As for CYF's risk assessment report, the manager's colleague at the September meeting told the family: "The picture that I'm getting is that a poor report ... not one of our best ... all I'm saying is the information that was given to the judge didn't actually concentrate and focus on the issues that we know that were happening in the home."
It did not help that social workers were not sure what the judge wanted. The CYF manager who did the review said it was unprecedented, "unique", for a district court assessing a bail application to ask CYF directly for a report like this.
"There wasn't a process for requesting those kind of reports and it kind of felt that Child Youth and Family weren't really clear what they were being asked to do," she tells the family in the recording they made.
"That reflected in the report, because the report wasn't perhaps as robust or as critical as we would have wanted."
Man allowed back home
The court went on to change the bail conditions, allowing the man back to the family home.
Some days later, CYF followed up with a weak safety plan for the boy and his sister.
It was based largely on interviews with the boyfriend and the mother.
There was no follow-up to make sure the couple stuck to the plan and no consequences if they didn't.
"We would have expected to see a stronger safety plan," said the manager.
"So you can say, I want you to do this, this and this, but if there's a potential you're not going to do it then how do I check that ... the reality is, at that point in time, they should have been erring on the side of caution."
At around the same time, the boy ended up in hospital with a spiral thigh fracture. He was examined and a broken tooth, crushed fingers and bruising were found.
Hospital staff were not convinced by the mother's explanation of how the toddler was injured, though a doctor said it was plausible that he could have caught his fingers in a door.
They had the pair under a 24/7 watch and warned CYF the woman was a suspect.
Meantime, the three-year-old sister was at home alone with the boyfriend in breach of the safety plan.
An agency file identifies both children as "unsafe" and said all precautions should be taken. But one day later, CYF and the police agreed the boy should be discharged.
The manager could not explain to the family why this happened.
She also admitted she did not talk to the police or the hospital about why this decision was taken.
"People were still saying we're not entirely sure how these injuries came about and we don't know whether we should be worried about how these injuries happened or not.
"I suppose, again, if we look at it with the benefit of hindsight, we were thinking, yeah, we probably should have been more worried."
Family told CYF fulfilled its statutory duties
In the end, however, the manager told the family that in general terms, CYF did fulfil its statutory duties in the case of the dead toddler.
The family said it had no confidence changes would be made.
"If we have recommendations that aren't able to be enforced, well, our nephew has died for nothing," said the father's sister, who supplied the recording to RNZ.
"And other families who have gone through this, their children have died for nothing. There needs to be a change."
She said the advent of the Vulnerable Children Ministry in April, in place of CYF, was a meaningless name change.
"You still have the same staff, you still have problems with under-resourcing, problems with your staff not being trained properly. You have staff who have clear bias against family members.
"This agency has processes in place that they admitted to us were not followed."
The police have also reviewed their handling of the toddler's case but say they can only consider releasing this after the inquest which is expected later this year, possibly in Invercargill.
Among the admissions made by the CYF investigator:
- That social workers should have asked tougher questions of the mother and boyfriend. "They've explored areas that we would have wanted them to explore but they could have perhaps explored them in some ways a bit more critically. So I would maybe have expected some tougher questions to be asked."
- That CYF did not look at other options for the boy at the time he was discharged from hospital, such as going into care.
- That warnings about the boyfriend from three sides of the family, including his own family, were not given enough consideration. "What we did recognise is some really different views about all the people involved here. One of the things we didn't do very well was actually say, lots of different views, let's not pick a view and go with that, let's just acknowledge that actually we don't know some of this."
- A "not great" risk assessment made to the district court. "If district courts are going to start asking Child Youth and Family for reports in those kind of situations we need to be really clear about, for what purpose, what's expected, what kind of information should Child Youth and Family provide," said the manager. "Because in this situation it was quite unique, because we'd never been asked for that kind of report before. It meant that social workers weren't really that clear about the kind of information they should be considering."
- The father and his family were not told the boy was injured and were not consulted on the safety plan, either at the time of the bail hearing or the hospital discharge. (The father was in jail at the time for assaulting the mother.)
Start of 2015 - Boyfriend's children move to North Island. Mother of the boy, who later died, and his sister move to Southland to live with boyfriend.
May - Boyfriend arrested for charges understood to include aggravated burglary and assault.
June - Boyfriend is granted electronic bail on condition he is not allowed to live at the family's home or be unsupervised with children.
August - Boyfriend applies to alter bail conditions so he can live at family's home; Corrections and police oppose this. District court asks Child Youth and Family for a risk assessment.
September - A CYF Care and Protection Resource Panel notes that the mother does not seem to be protective of the children.
September 21 - The mother takes boy to hospital with a sore leg but he is not admitted.
Late September or early October - After CYF submits its risk assessment to the court, the bail variation is granted and the boyfriend is allowed back to the house.
October 6 - The boy is hospitalised and x-rays show a leg fracture.
October 7 - Boy's fracture and three other injuries spark hospital social worker concern. Police begin investigation. 24/7 watch put on boy and mother. A CYF note said "alleged perpetrator unknown, possibly mother". A CYF report said both children were unsafe and all precautions should be taken.
October 8 - Doctor examines the daughter but the mother refuses to allow her to have a full skeletal x-ray. CYF and police agree the boy can return home.
October 13 - Boy found dead at home.
October 15 - Boyfriend appears in court, denies murder charge.
November 2015 - Boyfriend found dead in custody.
February 2016 - High Court orders stay on proceedings and permanent suppressions.
March - August 2016 - CYF reviews how it handled the case.
September 2016 - CYF manager outlines review to family. It won't give them a written copy; family secretly record the meeting.
February 2017 - Family provides recording and CYF correspondence to RNZ.