Failings in Child Protection Case 'Routine' and Still Happening, Doctor Says

A doctor who treated Malachi Subecz, a 5-year-old boy murdered in 2021, has revealed that the systemic failures in child protection were not an anomaly but rather a routine occurrence. The revelations come as a coronial inquest into Malachi’s death continues, highlighting ongoing issues in how child abuse cases are handled in New Zealand.

Dr. Patrick Kelly, a national expert in child protection and a paediatrician at Starship children’s hospital, testified at the inquest in Auckland. He described the injuries Malachi suffered as consistent with a sustained period of cruelty and, in some cases, torture. The boy had been bruised, burned, and malnourished when he was admitted to the hospital, and his injuries were clearly inconsistent with the explanation provided by his caregiver, Michaela Barriball.

Malachi’s mother, Jasmine Cotter, broke down in court while recalling her last phone call with her son. The inquest had previously heard that photographs of Malachi with visible bruising had been sent to Oranga Tamariki, the government agency responsible for child protection, by a family member months before his death. However, these photos were reviewed by social workers who concluded there were no specific concerns without involving a medical professional.

“It is of fundamental importance that the coroner appreciates that this behaviour by Oranga Tamariki was not an anomaly,” Kelly said. “I would go so far as to say it was business as usual.” He added that a similar pattern was seen in the police force, where evidence of child abuse was often ignored or dismissed without proper assessment.

Dr. Kelly reviewed the same photographs in court and described the combination of bruises as “unusual” and more likely to be deliberate than accidental. He also shared that two months after Malachi’s death, he treated another child with similar injuries who later died. In that case, a police officer had seen the child with black eyes and neck bruises but accepted the caregivers’ explanation that the injuries were accidental.

“Decisions to close a report of concern were arbitrary and widely variable,” Kelly said. “Often, they were made by police or child protection with little or no training in injury interpretation.”

Malachi’s case has led to a major inquiry, which recommended the government introduce mandatory reporting of child abuse. However, Dr. Kelly remains skeptical about the effectiveness of such measures. He pointed out that even if daycare staff had reported concerns, there was only a 50/50 chance that Oranga Tamariki would have investigated further, and even less of a chance that they would have consulted a health professional.

Between October 2021 and June 2022, 16 children were admitted to Starship with serious head trauma from abuse, and six of them died. “Malachi was only one of the 16,” Kelly said. “My question to both Oranga Tamariki and Dame Karen Poutasi—why do we seek to learn from what happened to Malachi and not the others?”

Dr. Kelly also criticized the lack of dedicated resources for child abuse assessments within the health system. He noted that Starship was the only dedicated, multi-disciplined facility in the country, and health professionals often had to “squeeze” child abuse assessments into their already busy workloads.

He called for greater collaboration between police, Oranga Tamariki, and the health sector. While law changes in 2019 allowed for greater information-sharing between the agencies, Kelly said the implementation had been inconsistent, leading to a “one-way traffic” system where health workers shared information with Oranga Tamariki but received nothing in return.

“My simple solution is that every time police or Oranga Tamariki receive an allegation of visible, physical injuries, that photo should be shared with a health professional and an assessment should be done as quickly as possible,” he said. “That process has to involve comprehensive, two-way information sharing between health, Oranga Tamariki, and police.”

Michaela Barriball was sentenced to life imprisonment with a minimum non-parole period of 17 years for murdering Malachi Subecz. The inquest continues as the country grapples with the broader implications of the tragedy and the need for systemic reform in child protection.