The removal of newborn babies from their parents without notice by Oranga Tamariki has become more "routine" than "exception", the Chief Ombudsman has found.
Taking newborn pēpi from their parents was one of the "strongest uses of state power", yet the agency was found to in most cases be making such decisions unnecessarily late and without expert advice, according to the report He Take Kōhukihuki: A Matter of Urgency released today.
Chief Ombudsman Peter Boshier launched his inquiry last year - one of four investigations into Oranga Tamariki's uplift practices, sparked by the highly-publicised uplift of a 6-day-old baby from his 19 year-old mother at Hawke's Bay Hospital.
Boshier examined cases of 74 pēpi from nine sites, aged up to 30 days old and who were subject to a section 78 custody application by the Ministry - without notice - over a two-year period, ending 30 June 2019.
In most cases the Ministry knew about the mother's pregnancy for months before the birth, meaning there was time to engage with parents, whānau, and other parties to determine the best place for pēpi, Boshier said.
"I found decisions were being made late, without expert advice or independent scrutiny, and without whānau involvement.
"This meant other options were often not fully explored, and in almost all cases a without notice application was made".
Boshier said high caseloads and limited Māori specialist staff were contributing factors.
"This appeared to result in cases involving unborn pēpi not being prioritised until the birth was imminent.
"I believe the level of urgency around a without notice section 78 application at the time of pēpi's birth was often created by the Ministry's inaction and lack of capacity to follow processes in a timely and effective way."
All the cases reviewed required a disability rights-based response from the Ministry, yet the investigation found these parents did not get the assistance or advocacy they required.
"I was very concerned to find the rights of disabled parents were not visible in either policy or practice", Boshier said.
"This is a significant breach of the [Disabilities Convention]."
Late and limited pre-birth planning, communication and information sharing with District Health Boards were also key issues.
"When the Ministry executed the removal decision, I found that parents and whānau were not provided with opportunity for ngākau maharatanga me te ngākau aroha; a period of 'quality time' that reflects consideration, empathy, sympathy and love."
There was also no support offered to parents and whānau to deal with the trauma and grief of their being pēpi removed, while mothers who wished to breastfeed got only limited support.
However, while he identified systemic issues, Boshier also acknowledged good practice at sites with formal partnerships with iwi and valued Māori specialist staff.
Boshier made 32 recommendations, including prioritising engagement with whānau, hapū, and iwi; and enhancing cultural competency of staff.
Oranga Tamariki carried out an internal review last year, which found major failings in the uplift of a 6-day-old baby from his 19 year-old mother at Hawke's Bay Hospital.
It found that Oranga Tamariki did not do enough to build relationships with the baby boy's family or explore placing him in the wider family.
Oranga Tamariki Chief Executive Grainne Moss said the agency welcomed the Chief Ombudsman's report and recommendations, and also noted it had made changes in November 2019 following its own investigation.
"Since our own changes in November last year I can confidently say we are working earlier with whānau and seeing fewer children coming into care.
"For those who do need to enter care it is more likely to be in a planned way and less likely to be under a section 78."
The number of babies (under 1) coming into their care had halved over the last three years, from 445 in 2017 to 220 in the last financial year.
Since 2017, there had been a more than 60 per cent reduction in babies (under 1) brought into their care under section 78 orders (from 288 in 2017 to 120 in 2020), Moss said.
There had been an increase in social worker numbers, with caseloads down from 31 in 2017 to 21 children per care and protection social worker.
Also since July last year, there were 38 Kairaranga-a-whānau and Māori Specialist Roles employed directly by Oranga Tamariki and five employed by iwi partners, with another 20 more roles to be established.
"We are committed to continuing to improve the way we work with whānau, hapū and iwi so we can better support the babies, children and young people who need it.
"In relation to disabilities, we agree this is an area where we need to do some significant work."
As of June 2019, 6429 children were in state custody, and 69 per cent of them were Māori.
Māori children aged between 0 and 3 months were five times more likely to be uplifted than non-Māori.