INVESTIGATION: CYF review shows social workers took shortcut to meet timeframe, then let case "languish" for months.
Social workers took "shortcuts" to meet deadlines when warned about a dysfunctional family of a baby who later died inside a hot car, according to a review of the death.
Staff at the Child Youth & Family office in Whakatane were routinely opening "assessment" records when safety concerns were raised about children, even if the assessment was not completed.
This was to meet internal performance timeframes, but often meant there was no urgency for social workers to finish the safety assessment.
"Unfortunately these shortcuts become 'normal practice' very quickly and there was resistance by some to return to best practice," the review author wrote.
Staff at the Whakatane site were told in September 2015 to stop opening assessment records early and clear the backlog of cases.
But this was too late for Isaiah Neil.
Several "reports of concern" about synthetic cannabis in his Ruatoki home had "languished" for three and a half months "without progress" before his death in November 2015.
The eight-month-old died of heatstroke after his mother and grandmother left him to sleep inside a car while they smoked synthetic cannabis in the house.
The Weekend Herald revealed in July there were 10 "reports of concern" for Isaiah or his older siblings over the three years before his death.
Three of those specifically mentioned their mother's addiction to synthetic cannabis.
"It is clear our practice could have been better and should have been better," the review concludes.
"It may not have prevented Isaiah's death but we will not have any opportunities to get it right for him again."
The review - obtained by the Weekend Herald despite the Ministry of Vulnerable Children refusing to release it under the Official Information Act - also identifies other problems and missed opportunities.
CYF staff involved failed to notice the clear pattern of behaviour and no one reviewed agency's involvement over the three years.
This meant the 10 reports of concern - exposure to family violence, mental health problems, addiction to synthetic cannabis and parenting ability - were treated in isolation without considering the context of the previous history.
And when CYF staff did follow up on the reports of concern to interview family members, they often failed to address the specific allegations.
This was particularly true about the repeated concerns about Isaiah's mother Lacey Te Whetu smoking synthetic cannabis regularly.
The lack of information in the reports, combined with failing to identify a pattern of behaviour, meant there were several "lost opportunities" to intervene.
"Resources have been available to social workers to support good decision making throughout this time but they have not been effectively applied, if at all," said the review.
"There have been many opportunities to gather better information that might have provided a more accurate picture of the family dynamics and functioning."
The CYF review of Isaiah's death confirms concerns held by relatives of Shane Neil, Isaiah's father, who spoke to the Weekend Herald last month.
They had earlier written to Social Welfare Minister Anne Tolley seeking answers and will soon meet senior management from the Ministry for Vulnerable Children.
Tayelva Petley, the Bay of Plenty regional manager for the Ministry, said monitoring of case activity in Whakatane had improved since Isaiah's death.
Changes include training to improve responsiveness, better record keeping and report writing, more comprehensive assessments to understand a family's history, and greater supervision for decision making.
"Isaiah's death was a tragedy...Our people feel it very deeply when we lose mokopuna. We all feel that responsibility and we always look to see what we could do better," said Petley.
"Obviously there has been some major system change in the last two years - and that's reflected in considerable change at a local level.
"One of the key things we are doing is formally working with other government agencies to connect up services. It's designed to ensure that children and families get all of the help they need and that there aren't gaps."
The news of social workers taking 'shortcuts' to meet KPI timeframes comes after a six-month Weekend Herald investigation into Isaiah Neil's death.
The eight-month-old died after being left in a car on a hot day for several hours outside his grandparents' home in Ruatoki, the Bay of Plenty, in November 2015.
Shane Neil was unaware his son was in the car, but did not call 111 when he found the infant "limp, unresponsive and hot".
Instead, Isaiah was placed in a cot for another three hours while his parents slept off the "zombie" effects of smoking synthetic drugs.
Neil pleaded guilty to manslaughter and was sentenced to 10 months' home detention, while Isaiah's mother, Lacey Te Whetu, and grandmother, Donna Parangi, were jailed for three years on the same charge.
The two women left Isaiah to sleep in the car - with the windows and doors shut - so they could smoke synthetic cannabis inside the house.
For this reason, Justice Graham Lang found them to be more culpable than 31-year-old Neil for the death.
Home detention was granted as the evidence was unclear if Isaiah could have survived even if Neil had called 111.
In an exclusive interview with the Weekend Herald last month, Neil says he felt the sentence was lenient.
"I feel lucky to not be in prison. I'd agree with some of the public who thought that wasn't long enough.
"I do blame myself ... I failed. The last two years have been like waking up from a bad dream every day. Except it's not a bad dream, it's reality."
The life and death of Isaiah Neil
24 November 2012:
Relative of Shane Neil calls CYF with concerns about Lacey Te Whetu. Told to call police if urgent, or call CYF back.
27 November 2012:
Report of Concern by Neil. Children being exposed to drugs and domestic violence. Later calls back to retract allegations. CASE CLOSED.
REVIEW COMMENT: 'Given the circumstances it is possibly acceptable not to take the report of concern any further, however the detail in Shane's report tends to suggest that the concerns were not entirely fictitious'.
19 September 2013:
Report of Concern by relative of Neil. Long email about domestic violence, drugs and alcohol, poor parenting comparing family environment to Nia Glassie death. Social workers interview Te Whetu, Plunket nurse and midwife. CASE CLOSED.
REVIEW COMMENT: The information provided makes it evident that [the relative] has good knowledge of child development and insight into the dynamics of violent relationships and enabling behaviours.
18 December 2013.
Report of Concern by Neil. About Te Whetu's's discipline of children and use of synthetic cannabis. Social workers visit house and accept Te Whetu's explanations. Neil also charged with assault. CASE CLOSED.
19 December 2013:
Report of Concern by police. Relating to Neil's assault charge. He later pleaded guilty. CASE CLOSED
REVIEW COMMENT: The Tuituia report does not reflect the new concerns...the worries were about Lacey's behaviour and a specific incident of family violence.
26 March 2014:
Report of Concern by police. Neil wanted to take daughter to Hamilton because of safety concerns about synthetic cannabis, Te Whetu wanted police to stop him. Police advise they could not intervene without parenting order. CASE CLOSED
REVIEW COMMENT: The Tuituia report again did not reflect the concerns raised. The issue of Lacey's significant use of synthetic cannabis has not been explored at all.
27 March 2014:
Te Whetu obtains parenting and protection orders in Family Court against Neil on grounds of previous assault.
2 July 2014:
Report of Concern by relative of Neil. About children being exposed to violence and drug abuse. As there was no specific incidents raised, no further action. CASE CLOSED.
REVIEW COMMENT: While this was not new information, it needed to be assessed in the context of previous family history...the patterns of behaviour could be predicted to identify future harm to the children. This was a lost opportunity for CYF to become involved.
29 July 2014:
Report of Concern by Neil. Te Whetu had threatened to harm herself and alleged abandonment of children. CASE CLOSED.
REVIEW COMMENT: Another lost opportunity to identify needs and risks to the children as a result of their mother's behaviour. As an isolated incident it may not have been overly significant but in the light of the history it was a clear predictor of future harm.
26 May 2015:
Report of Concern by police. Te Whetu charged with wilful damage and common assault against Neil. Allegations of synthetic cannabis. CASE OPEN
4 July 2015:
Report of Concern by Neil. Same incident, repeats allegations about Te Whetu's synthetic cannabis use. CASE OPEN
31 August 2015:
Report of Concern by police. Kylie Te Whetu removes Isaiah's siblings from her sister because of synthetic cannabis. CASE OPEN.
REVIEW COMMENT: Lacey's behaviour is clearly identified as putting her children at serious risk of physical and emotional harm...at a minimum a Child and Family Consult would have directed a way forward, identified goals and highlighted how unsafe the children were...the practice of opening an assessment record to meet timeframes rather than because an assessment has been completed, has contributed to the lack of urgency in acting for these children.
2 November 2015:
Isaiah Neil dies after being left in a hot car.