A family living in fear of their young son's increasingly dangerous behaviour asked Oranga Tamariki for support. Instead, the ministry turned its focus on his mum.
The baby rabbits mysteriously start dying in spring. Their mutilated bodies are found inside the locked and escape-proof cage, leaving Claire* stumped.
She breeds the rabbits on their rural lifestyle block with her husband Paul* and their five children.
When 24 more rabbits die en masse a few months later, Claire rings the vet, who suggests they may have been poisoned.
To the couple's horror, Claire's second eldest son from a previous relationship, Noah*, calmly admits to putting rat poison in the rabbits' water and food.
Noah is eight years old.
It's not an isolated incident. Noah has been displaying increasingly strange and worrying behaviour over several months, including contaminating the family's food stores with pig swill, tampering with his baby brother's formula and bottle, and cutting electrical wires in the family's car.
When he starts sneaking out at night to light fires, Claire and Paul are so scared they take turns staying up all night to watch him.
In April 2021, their GP refers Noah to the local child and youth mental health services for an assessment.
The same day, Noah's counsellor is so concerned about the family's safety that she sends - with Claire and Paul's support - a report of concern to Oranga Tamariki for the four other children in the home, telling the Children's Ministry that "urgent support" is needed given Noah's "increased unsafe behaviours".
While they are still waiting for a mental health service appointment, Claire lights a fire with wood collected by Noah and a foul smoke fills the house, causing them to retch and vomit, and their eyes and throats to burn.
When Claire asks Noah if he's put something on the wood, he admits he did, but refuses to say what.
"I was begging him to tell us - but he wouldn't say."
So she smacks him.
"I was so sleep-deprived and so desperate. I wasn't thinking straight."
It's an action she immediately regrets and she apologises to her son.
She will regret it for longer than she thought possible - because as she will find out, Oranga Tamariki believes the real danger to this family is not Noah, but Claire.
Two reports of concern - and a wait for help
In the moments after the smack, Claire remembers Noah going from "hysterical to absolutely calm" in an instant..
Unnerved, Claire calls the crisis team immediately.
The hospital arranges for an urgent assessment for Noah, and he goes to stay with his biological father for a few days to give the family some respite.
The next day, the mental health team gives Noah a preliminary diagnosis of conduct disorder, a group of serious emotional and behavioural problems in children and adolescents that occurs in around four percent of the population.
The hospital is also worried about the family's immediate safety, as Noah is due to return home the next day. So, again with Claire and Paul's consent, a staff member files a separate urgent report of concern that evening.
A 'report of concern' is a formal notification made to Oranga Tamariki if someone believes a child is in danger. The ministry has a statutory responsibility to assess the situation within 24 hours to 10 days, depending on the urgency. By law, an 'urgent' notification must be responded to within 48 hours.
"[Noah] has intent and will find means to seriously harm his family and or animals," the hospital says in its report to OT. "Children in the home are at risk of being seriously harmed by their brother. Parents are burnt out, sleep deprived and asking for urgent support to keep their family safe."
The report incorrectly states that Claire smacks Noah regularly. The hospital will later apologise for this error and correct the information held on its file.
The original report of concern from Noah's counsellor notes Claire and Paul are "normally very competent and capable parents who provide everything a family needs and are very reliable, responsible, caring caregivers".
It's Noah's behaviour that concerns the counsellor. "There are safety concerns for the four other children, including 3 under the age of 5 years, as well as safety concerns for the parents," the counsellor writes.
When the hospital fails to hear back from OT, a staff member calls the ministry the next morning.
"The report of concern is for his siblings, he is at risk of poisoning and killing them," she tells the social worker on the phone at 9:02am.
The counsellor hasn't heard back about her report of concern either, so her boss emails a team leader at OT.
"The child's behaviour is escalating," she writes, urging the ministry to create and implement a safety plan for the family.
Nothing happens.
OT and the hospital tell Claire and Paul that it's too dangerous for Noah to return home until there are "supports and a safety plan" in place, so he remains with his father.
OT also tells Claire they can't provide any support without a formal diagnosis for Noah, so the couple scrape together money to pay for a private psychiatrist, who formally diagnoses Noah with severe conduct disorder.
With a diagnosis and treatment plan in place, OT engages a community organisation to assess Claire and Paul's parenting and identify risk and safety issues.
The assessment says it does not believe Claire and Paul are abusive.
"This family need help, but it's actually in how to keep all the kids safe, not so much parenting," the report sent to OT says.
It also suggests the couple make changes to make their home safer, including the possibility of installing cameras that would alert them if Noah wakes up at night.
Claire and Paul borrow money to make as many of the suggested changes as they can.
"We built him a new room, we installed locks on all the cupboards and pantry - we stretched ourselves to the financial limit, so we could not afford the cameras," Paul says.
"We asked OT if they would pay for the cameras several times, but they wouldn't respond and even disputed whether we had even asked them in the first place."
There's still no help or safety plan in place when Noah returns home in June.
He starts acting up again at night while everyone is sleeping, crushing dishwashing tablets into baby bottles, contaminating the family's food again and slashing power cords on tools.
Claire and Paul are increasingly sleep-deprived trying to watch Noah each night. With no help offered from OT, they eventually decide to lock Noah in his room at night.
Noah's psychiatrist supports the temporary move, telling OT it is "much more likely" Noah could seriously injure the family, compared to the "very small risk" of any harm being done to him by being locked in his room.
"It has been discussed with him and he is not distressed about it… It is in my mind the least restrictive option available to maintain everyone's safety," the doctor writes in a letter to the ministry.
Oranga Tamariki disagrees with his assessment, however - and Claire is about to discover why.
What the documents revealed
In the background, OT has formed a different narrative, brought to light after Claire obtains part of her file from the ministry, as well as documents from other agencies.
She is shocked at what she reads.
Of the two urgent reports of concern, one is missing and the other is misfiled as a case note. Only a few pages of it are lodged in the ministry's online case management system, called CYRAS.
The report of concern from the hospital was assessed by OT, but despite the concerns the hospital raised about the risks to the entire family, the ministry has concluded it is only Noah at "critical risk", from Claire's smacking.
The safety of Noah's siblings is never assessed as required by law.
OT does not get in touch with the counsellor regarding her report of concern for four months.
Noah's initial conduct disorder diagnosis is missing from the file, and warnings from health professionals about the risk he poses are either ignored, missing or watered down - often retrospectively.
Instead, OT appears to be solely focused on Claire's behaviour. The ministry is worried about her smacking Noah after the fireplace incident, and that she locks him in his room.
"This can also impact [Noah's] emotional wellbeing and self-esteem if he is caged every night," an OT assessment notes.
It believes Noah and his siblings are at "critical" risk from "ongoing physical abuse" from Claire.
Unbeknown to Claire, around the same time she receives her file, Chief Ombudsman Peter Boshier finds a litany of errors, unverified information and poor social work led to OT wrongly removing another child from her grandmother's care.
He criticises the ministry's poor record-keeping and back-dating of case notes in that situation.
In Claire's file, documents show social workers held a meeting to discuss the family's situation, but the danger Noah presented to his other siblings is never mentioned.
A case consult in June 2021 shows the purpose of the meeting is to assess "how safe is [Noah] with mum?", with social workers questioning Claire's mental health.
The documents show OT suspects Claire of "medical abuse" towards Noah, claiming these concerns are first raised by medical professionals.
"[Regional youth forensics service] have told us that they're concerned about some of the mother's behaviours and indicated there may be an element of medical child abuse," it notes.
But these concerns are not noted in any of the documents Claire later obtains from the hospital or the forensics service, and she says both agencies later tell her they never raised it with OT as an issue.
OT refuses to tell Claire where these allegations came from.
OT is so concerned about Claire smacking Noah, it even alerts the police, telling them it is not happy with the care being provided by her.
When a police officer visited Claire at home in May, she thought it was to discuss Noah's behaviour. She says she told the officer about the smack, but he wasn't concerned.
"Under the circumstances I think it's unjust to mark the parents as 'suspects' for an offence," he writes in his report.
This report, too, is never added to the family's OT file. Claire only discovers its existence when she also asks the police for the document.
This leaves Claire distraught.
"Instead of actually looking for help for Noah, it's a witch-hunt on me. All the concerns about the risks to our children were ignored and there was just the risk of smacking."
Paul's concerns about his younger children's safety, and pleas for help for his step-son, are neither recorded nor considered by OT.
"It seems anybody who suggested Noah needed to get help in some way or form, it has disappeared," he says.
"[OT] said all Noah's behaviours were only described by my wife and no one else."
OT also denies attending a group conference of health professionals where Noah's diagnosis of severe conduct disorder is discussed and concerns for the safety of his siblings were raised.
"We had to get documents from the hospital showing they did attend, but they are missing from OT's file," Paul says.
Claire estimates there are at least 52 documents relating to the family that are potentially missing, incorrect, or have been altered.
The urgent email from the boss of the counsellor who made the first report of concern was also never noted on the family's file by OT. The ministry only locates it after Claire and Paul lay a complaint about the missing documents and the way they have been treated, forcing it to do a deep dive into the records.
That search turns up dozens of documents the family has never seen, or even knew existed, that had not been added to the family's file.
"They spent a year-and-a-half deep-diving to get the information. They told us they would work with us to correct any incorrect information, but so far they haven't," Claire says.
While all this is going on, Noah's behaviour continues to escalate and he moves in with his father permanently, where his behaviour improves.
Eventually, Claire loses custody of her son after OT files inaccurate information about her with the Family Court - which it later apologises for.
The decision is devastating, yet Claire is too scared to let Noah come home. Soon after he moves out, Claire finds a note under his bed scrawled in his handwriting: "Plan: poison kids, kill rabbits, kill pigs."
"We didn't want him to leave us, but we just couldn't keep him at home," says Claire.
She and Paul believe things would be different if OT had not been so focused on Claire's behaviour, and had been willing to provide the help they needed to keep Noah at home.
"OT has caused us more harm than good," Paul says.
An inconsistent response
During the same period that Claire and Paul were struggling to get help from OT, five-year-old Malachi Subecz is murdered by his carer in November 2021, in a case that shocks and outrages the nation.
An independent review by Dame Karen Poutousi a year later finds Subecz's whanau had raised concerns about his care with police, his daycare and OT, but OT had decided no further action was needed.
She found "critical gaps" in the country's child protection system and recommended a host of changes to stop vulnerable children from falling through the cracks.
Fast-forward nearly three years and not much has changed. In August, a review of the child protection system and Dame Poutousi's recommendations, carried out by Aroturuki Tamariki (the Independent Children's Monitor), found children are no safer now than when Subecz died.
"Sadly, very little progress has been made," Aroturuki Tamariki chief executive Arran Jones says.
His report found that OT receives about 80,000 reports of concerns a year, but around half of them are marked as needing 'no further action'.
The most troubling issue for Jones is that the response to these reports of concerns largely depends on where you live.
"In Christchurch, you've got a much lower response rate from Oranga Tamariki than you would in Tāmaki [Auckland]," he told RNZ.
"So you're getting an inconsistent response. And what we heard from Oranga Tamariki's own staff is that the decisions they are making are unduly influenced by the resources available, not based on the risk to the child."
Funding cuts to community organisations contracted by OT, which the Auditor-General is now investigating, will put further pressure on social workers to assess these reports, Jones believes.
"A report of concern might come in that Oranga Tamariki may assess and decide the risk isn't high enough for them to intervene. But they may want a community organisation to visit the family, get eyes on the child and make an assessment.
"This kind of partnership is critical, and what we are seeing and hearing is a reduction in the funding for these organisations. And that is a concern."
Chief Ombudsman Peter Boshier is also concerned.
Despite promises of change after Malachi's death, last month he again found OT had failed to properly investigate multiple reports of concern about assaults and violence against very young children in one family, with incomplete and poor record keeping at the heart of the case.
In this case, he found OT had filed inaccurate and biased information with the Family Court.
"One of the recommendations was that Oranga Tamariki apologised to the family court and set the record straight. And I believe that's happened."
But as RNZ reported earlier this week, Boshier believes there is a pattern of OT filing incomplete or biased information with the court in order to achieve a certain outcome.
OT says it "strongly rejects" any suggestion this is a systematic or routine practice, saying it has happened in a small number of cases, but it always corrects any wrong information.
An apology - but few answers
Last year, the ministry admitted some of Claire and Paul's experiences "were not acceptable".
"It is apparent Oranga Tamariki has not always met its obligations under Principle 6 and Principle 8 of the Privacy Act 2020 in respect to keeping or providing accurate records," it wrote to the couple in March 2023 after investigating their complaint.
It blamed the pandemic for some of its failures.
"While it is not acceptable for some of the experiences you've had, particularly the record keeping and the tamariki not all being assessed; COVID-19 had an impact on social workers ability to practise in their environment and usual manner," it wrote, outlining its investigation findings.
It also apologised for not following the "correct statutory process" in responding to the reports of concerns for the three youngest children, and for providing incorrect information to the Family Court due to incorrect or missing information on its files.
In a formal letter of apology it said it was willing to work with Claire and Paul to correct any wrong information it held about them, but the couple say they can't do this until they are given a full copy of their files to check.
"So many changes have been made to the file, that unless we have a full up-to-date copy, it would take too long for us to check ourselves. They have not corrected it - any corrections are just added to the file at the end, but not in the right place," Claire says.
The letter says OT has since "reflected on [its] record keeping and following processes".
More than a year on from that apology, though, the agency still cannot explain why or how so many records went missing or were altered in the first place.
Claire says OT still refuses to tell her where the accusations of medical abuse came from, and specific questions put to the ministry from RNZ about that are also not answered.
Unhappy with the response, the Ombudsman and the Privacy Commission are now investigating Claire and Paul's case.
Concerned about breaches of the Public Records Act, the couple also filed a complaint with Archives New Zealand. But after a year of investigation Archives passed it back to the Ombudsman to look at.
Claire says other complaints laid with the ministry are yet to be addressed, including allegations that Paul regularly smacked the children as well.
OT, however, says it has "completed" the complaints process with the family.
"We acknowledge that the documentation of information in this case could have been better, and we have apologised for the record keeping of this case," Oranga Tamariki National Commissioner North Alison Cronin said in a statement.
"The complaints process for this case, including the complaint recommendations, has been completed.
"As the matter is under investigation by the Ombudsman it would be inappropriate to comment further at this time."
Claire says OT's response is disappointing, and the lengthy complaints process a joke.
Claire and Paul would like to set the record straight with the inaccurate information filed about them in the Family Court too, but say they've been told by OT they cannot do this.
It's yet another battle the couple must fight in the four-year ordeal with the ministry they say has left them defeated.
"We were told by all professionals involved that OT would help us, and that they were the only ones who could help us," Claire says.
"I don't understand why it did not work with us from the very beginning to get my boy home. Now I have no relationship with my son at all."
Paul believes both the internal and external complaints processes take too long.
"I believe there should be an independent body overlooking OT, the same as the Independent Police Conduct Authority, to escalate complaints and make sure OT is doing its job properly," he says.
"It's destroyed us to have to give up on a child like this," Paul adds.
"If we had been given the support we needed, then perhaps we could have kept him at home.
"This has broken our family."
