A coroner investigating the huffing death of an Auckland teenager has highlighted “systemic failings” by Oranga Tamariki, including missed opportunities for intervention and failure to address the teen’s cumulative harm since birth.
Ruby Rose Tear, 14, died from accidental butane inhalation – known as huffing – at her grandmother’s West Auckland property in May 2021.
The teenager was in the care of Oranga Tamariki at the time and had been placed at a residential facility.
But she absconded and died hours after arriving “unexpectedly” at her grandmother’s Whenuapai home.
Ruby’s death was referred to Coroner Alison Mills, whose findings can now be published.
“The purpose of this inquiry and findings is to determine the cause and circumstances of Ruby’s death and to consider whether I can make any recommendations or comments that may reduce the chance of deaths in similar circumstances,” the coroner said.
Coroner Mills outlined how Ruby’s mother had a long history of alcohol misuse, with ongoing concerns about her ability to care for her children.
OT was involved “intermittently” throughout Ruby’s life, and after her mother died of cancer in November 2018, granted her grandmother custody.
“Following the death of her mother, Ruby’s behaviour deteriorated quite rapidly. [Her grandmother] refers to her as mixing with a ‘bad crowd’, running away from home, stealing vehicles, and getting into trouble,” said Coroner Mills.
“In 2019, Ruby was stood down from school for five days on two occasions. [Her grandmother] stated that while she had had no concerns for Ruby’s physical health, she had had concerns about her mental health [saying Ruby] ‘was quite troubled and out of control’.
“Her grandmother also confirmed that she knew Ruby had started smoking cannabis and had caught her huffing once.”
By the age of 13, Ruby was known to police for running away from her grandmother’s care and stealing the woman’s car, shoplifting and using drugs.
Coroner Mills said Ruby had “been involved in a car crash and other criminal activities” and police had made numerous reports of concern to OT.
A report of concern is a formal notification made to OT when someone is worried about the safety or wellbeing of a child or young person.
Ruby’s grandmother also reached out for help from OT, the school and through her GP.
“Ruby’s grandmother clearly tried her best to care for and support Ruby,” said the coroner.
“However, in reality, she was left very much on her own to manage Ruby’s deteriorating behaviour.”
In mid-2020, Ruby moved in with a friend and her family, almost an hour’s drive away.
This caused her grandmother “significant distress” as she did not want Ruby to leave the family home.
“[The grandmother] did not know this family, and the friend was several years older than Ruby,” Coroner Mills said.
“Ruby lived at her friend’s house for about nine months. [Her grandmother] sought help, without success, from the police youth engagement team and OT as she wanted Ruby to be returned to live with her.
“She believed that the friend Ruby was living with was a ‘bad influence’ and wanted Ruby to return to mainstream education.
“[The grandmother] was surprised to be told, that despite her concerns for Ruby’s safety, OT thought she was old enough at 13 to make this decision.”
Coroner Mills said throughout 2020 and 2021, Ruby’s behaviour was “problematic” and she continued to “engage in anti-social and criminal activities”.
A social worker was appointed to work with Ruby in April 2021. By then, the teen was “huffing regularly” and smoking cannabis.
Huffing involves inhaling vapour or fumes from everyday household products, such as glue, cleaning products or paint, and produces a high similar to the effects of alcohol.
In late April 2021, Ruby had a fight with her friend and moved out of her house.
She “lived on the streets sleeping in the reserves and parks” and “would huff about once a week”. In the lead-up to her death, Ruby and some friends stole a car and made their way to Wellington.
When police located her, she was flown back to Auckland, escorted by an OT social worker and placed in youth accommodation.
Ruby walked out at 1.05pm the next day.
Coroner Mills said Ruby turned up at a friend’s house in Onehunga and they spent the afternoon together.
The friend’s mother picked them up about 10.20pm and dropped Ruby at her grandmother’s house at 11pm.
The grandmother said she and Ruby stayed up and “talked for a couple of hours” about what the teen had been doing.
Ruby was “okay” with her grandmother calling OT to advise that she was home.
“Ruby told her grandmother that she was wanting to get her life back on track, and to stop getting into trouble. They talked about going shopping for some clothes for her in the morning and Ruby told her grandmother she wanted to move back in with her,” said Coroner Mills.
“Other than Ruby having lost a lot of weight, her grandmother did not notice anything unusual with Ruby that evening.”
When her grandmother went to bed at 1am, Ruby said: “Good night Nana, see you in the morning”.
At 4.18am she video called a friend.
“At some point in their conversation Ruby went quiet and fell asleep,” said Coroner Mills.
“[The friend] states she asked Ruby what was going on and Ruby had responded that she ‘just fell asleep, my eyes rolled back, I couldn’t help it’.
“[The friend] did not think anything of it. She just assumed Ruby was tired as it was nearly 5am. They talked a bit longer, then Ruby seemed to fall asleep, and it went dark, so [the friend] hung up.”
At 8am, Ruby’s grandmother went downstairs and found her slumped across a chair, as if she had fallen.
“[The grandmother] thought it was a funny way to sleep so tried to wake Ruby but got no response. She then realised that she looked unconscious or dead and when she touched Ruby, she realised she was cold to touch,” said Coroner Mills.
“Sadly, Ruby was declared deceased by emergency staff on their arrival. Police found a ‘pipe or bong’ used for smoking cannabis and some used cigarette butts in Ruby’s hoodie pocket.
“No obvious evidence associated with huffing was found at the house.”
OT confirmed it became involved in Ruby’s life before her birth when an Auckland hospital social worker raised concerns when her mother was pregnant.
“However, following further meetings and assessments, it was determined that OT involvement was not needed,” said the coroner.
After Ruby’s premature birth, OT undertook further assessments as to whether there were care and protection concerns but determined in March 2007 to close the case as “Ruby was meeting her milestones”.
There continued to be intermittent but regular contact between OT and the family, with concerns raised about issues of drug and alcohol use, gang involvement, verbal abuse and neglect, but no further action was taken.
“In the three months before Ruby’s death, OT had increased involvement with Ruby as her behaviour continued to deteriorate,” said Coroner Mills.
OT undertook a “practice analysis” after Ruby’s death, comparing the actions it took against its practice standards.
“It identified a number of failings and missed opportunities,” said the coroner.
Coroner Mills said OT noted the multiple reports of concern since Ruby’s birth and a “failure to take this history into account when planning and assessing Ruby’s wellbeing”.
“There was no evidence that any assessments for psychological distress, substance abuse or risk of suicide was ever undertaken or that Ruby was referred to grief counselling following her mother’s death,” she said.
OT failed to properly support Ruby “within her family” and by not considering the impact on her schooling when she moved to live with her grandmother.
There were also “a number of delays in visiting and engaging with Ruby following events or reports of concerns”.
The analysis made a number of training and other recommendations to improve staff practice, said Coroner Mills.
Ruby’s grandmother expressed concerns about the circumstances leading up to the teen’s death and that OT did not support her as a guardian.
“[She] questions whether, with the right support, they might have saved Ruby, who was a young person with potential,” said the coroner.
“She does not believe she was asked about her views and felt sad and helpless. [She] would like to prevent similar events occurring and commented that there needs to be improved communication, partnership and support for guardians.”
“She commented she had a court order in favour of her caring for Ruby and she would have expected that the government agencies charged with the protection of children would have supported her as a concerned grandmother.”
Coroner Mills acknowledged the grieving grandmother’s concerns.
“There seems to have been missed opportunity after missed opportunity to really engage with Ruby’s family,” she said of OT.
“As noted by the review, the failure to consider the effects of cumulative harm is concerning. I am surprised by the lack of real engagement or an assignment of a social worker until it was really too late, and Ruby had left school and her behaviour had become entrenched.”
The coroner said her role was limited to investigating the circumstances of Ruby’s death and not to review in detail the services provided by OT to Ruby and her whānau.
However, she said Ruby was a young and vulnerable person who was offered insufficient support throughout her life to have the resilience to cope with the trauma of losing her mother.
“I also find it difficult to accept that a 13-year-old who is known to OT since birth and whose mother has died was permitted to run away from home and remain at another home without a thorough process, assessment, plan and full whānau engagement.”
Coroner Mills said
there were clearly numerous missed opportunities to intervene and provide support and services to Ruby and her grandmother.
“Ruby’s death is a very sad reflection of these ongoing repetitive systemic failings over her life.
“There is, however, no single incident or intervention that I can point to that may have changed the trajectory of Ruby’s life or prevented her death.
“I therefore simply reinforce OT’s own internal practice analysis findings and encourage OT to ensure all their staff are provided with the ongoing training, skills and resources to address the failings this analysis identified.”
Coroner Mills said OT had accepted the findings and acknowledged Ruby’s grandmother should have been provided with better communication, support and resources.
“OT advised that all of the recommendations that arose from the practice analysis undertaken after Ruby’s death have been completed.”
Anna Leask is a senior journalist who covers national crime and justice. She joined the Herald in 2008 and has worked as a journalist for 19 years with a particular focus on family and gender-based violence, child abuse, sexual violence, homicides, mental health and youth crime. She writes, hosts and produces the award-winning podcast A Moment In Crime, released monthly on nzherald.co.nz
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