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.
Oranga Tamariki was involved “intermittently” throughout Ruby’s life and after her mother died of cancer in November 2018, it 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,” Coroner Mills said.
“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 Oranga Tamariki.
A report of concern is a formal notification made to Oranga Tamariki when someone is worried about the safety or wellbeing of a child or young person.
Ruby’s grandmother also reached out for help from Oranga Tamariki, the school and through her GP.
“Ruby’s grandmother clearly tried her best to care for and support Ruby,” the coroner said.
“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 Oranga Tamariki 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, Oranga Tamariki 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 Oranga Tamariki 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 Oranga Tamariki 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,” Coroner Mills said.
“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,” Coroner Mills said.
“[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,” Coroner Mills said.
“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.”
Oranga Tamariki 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, Oranga Tamariki 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 Oranga Tamariki 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, Oranga Tamariki had increased involvement with Ruby as her behaviour continued to deteriorate,” Coroner Mills said.
Oranga Tamariki 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,” the coroner said.
Coroner Mills said Oranga Tamariki 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.
Oranga Tamariki 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, Coroner Mills said.
Ruby’s grandmother expressed concerns about the circumstances leading up to the teen’s death and that Oranga Tamariki 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 Oranga Tamariki.
“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 Oranga Tamariki 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 Oranga Tamariki 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 Oranga Tamariki’s own internal practice analysis findings and encourage Oranga Tamariki to ensure all their staff are provided with the ongoing training, skills and resources to address the failings this analysis identified.”
Coroner Mills said Oranga Tamariki had accepted the findings and acknowledged Ruby’s grandmother should have been provided with better communication, support and resources.
“Oranga Tamariki advised that all of the recommendations that arose from the practice analysis undertaken after Ruby’s death have been completed.”
In a statement provided to the Herald, Oranga Tamariki chief social worker Nicolette Dickson said Ruby’s death was a “tragedy”.
“I would like to extend my condolences to her whānau and all those who loved her,” she said.
“The coroner did not identify any one single incident or intervention that may have changed the course of Ruby’s life or prevented her death but noted there were missed opportunities to provide Ruby and her whānau with the support they needed.
‘We acknowledge and accept the coroner’s findings, which align with our own practice analysis, completed following Ruby’s death.
“The practice analysis found that our work with Ruby fell short of the standards we would expect in our practice. In particular, Oranga Tamariki did not do enough to act on the concerns raised about Ruby, and we did not provide adequate support and communication to her whānau.
“Our practice analysis made a number of recommendations, all of which have been completed. These focused primarily on emphasising the importance of our practice standards with our leaders and staff, including a focus on responding to cumulative harm over time, seeing and engaging tamariki and their whānau, ensuring professional supervision and keeping accurate records.
“Since Ruby’s death in 2021, Oranga Tamariki has focused on making significant changes in our practice. This includes introducing a new practice framework, models and tools focused on providing relational, inclusive and restorative practice. We have provided national training on this approach as well as establishing a stronger induction programme for our new social workers and programmes for our supervisors and practice leaders.
“As a result, we are beginning to see improvements in our engagement with whānau, stronger assessment and planning and more evidence of working collaboratively with partners in the community. We remain focused on continuing to strengthen our practice and how we work with other agencies to make it easier for young people like Ruby to get the support they need.
“Finally, I would again like to acknowledge Ruby’s tragic death and extend my profound sympathy to all those who loved her.”
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.