Oranga Tamariki's handling of an attempted uplift of a 6-day-old baby from a young mother in June was shameful.
And while Oranga Tamariki boss Grainne Moss was quick to own the agency's mistakes, she undermined her own credibility by failing to do the same for herself.
The internal review into the Hawke's Bay case, released today, said it was right for Oranga Tamariki to be involved, but the way it went about it was riddled with errors.
These included "little evidence" of attempts to build relationships with the father and mother, poor consultation with the wider family, and an over-reliance on historical information that clouded professional judgment.
• Damning Oranga Tamariki review: Gaps in the work, poor consultation and relationships
• Punched, struck, kicked: Assaults on Oranga Tamariki staff increase
• Oranga Tamariki signs agreement with North Island iwi Tūhoe
• Premium - Sexual grooming former Oranga Tamariki social worker sentenced to home detention
The risk assessment report should have been based on engagement with the family and other professionals, but in this case it was based on the views of a single Oranga Tamariki employee.
Furthermore, no notes were recorded about the rationale behind the decision to apply for an uplift order - which the Family Court approved in May.
Today Moss said the staff involved in the case faced serious consequences.
She spoke repeatedly about the need to own the mistakes, apologise to the family, and have the courage to bring about the changes needed to prevent history repeating.
But her resolve evaporated when she was asked about her initial response to the story, which was publish by Newsroom in June.
In the days following that report, Moss said that the Newsroom video was 40 hours of footage condensed into a 40-minute clip.
At the time she said: "I would say there's a very significant misrepresentation of the total story. We bring them into care with the approval of the courts after we've provided evidence that, actually, this may be the only way to keep that child safe."
Today Moss repeatedly dodged questions about whether her comments were wrong, if she regretted them, or if they might have inflicted further harm on the family.
The only sign she gave that the comments might have been misplaced was when she said that "emotions were running very high".
Minister for Children Tracey Martin has also mentioned the amount of footage taken versus the length of the Newsroom clip, which neither she nor Prime Minister Jacinda Ardern watched.
Martin said today she was not trying to fling mud at the family, but such comments - intentional or not - call into question the story's and the family's credibility.
Today's review recommended a number of changes to be implemented immediately.
Those included ensuring families have a say in all interim custody orders, where there is no clear need for urgent action.
In urgent cases, such as in the Hawke's Bay case, sign-off will be needed by a regional legal nanager, a site manager and a practice leader.
Moss says she is the person to lead this change. She has not offered to resign.
But if she had wanted to bolster public confidence in herself, it would have been helpful to extend today's mea culpa to herself.