A Family Court judge and lawyer are gravely concerned a young person will die - either by their own hand or through their dangerous behaviour - because Oranga Tamariki cannot find them a secure place to live.
They say it is simply not safe for the young person to live in the community and have been begging OT for months to find a space for the person in a secure residential facility. So far, however, their cries for help have been repeatedly unanswered.
OT claims it is doing everything it can to protect the young person and there is simply nowhere more secure for them to be placed.
Judge Jane McMeekan was so worried about the young person she alerted the Children's Commissioner, who said he was not at all satisfied with OT's care and demanded immediate action.
As of today, the young person is at a property with a 24/7 security guard and a source said their support people were beside themselves with worry, fear and frustration.
The Weekend Herald was granted access to Family Court documents that outline the sad and shocking case a week before a damning review found OT was a "weak, disconnected and unfit" agency.
The young person - who cannot be identified for legal reasons - became a ward of the state under the care of OT in December 2019.
The young person's parents consented to OT becoming the person's guardian after it was deemed there was "a real risk to their personal safety" and they were "in danger of physical, sexual and psychological harm".
The young person's family wanted to support them but they have complex difficulties and a "major depressive illness".
A plan was put in place for their care and welfare which was approved by the Family Court.
Three months later that was reviewed by Judge McMeekan, who took over the case to ensure it was handled with consistency.
Initially, the young person was doing well but by March this year they had spiralled and Judge McMeekan was "extremely concerned".
At the time the young person was living in an OT-supervised group home and while their immediate social workers and supervisors were praised for their work, Judge McMeekan said the young person was "simply not safe" at the property.
The court heard the young person was regularly running away - once for up to a week - and "associating with known child sex offenders and gang members" and using drugs and alcohol.
The young person's mental health had also declined, with further serious conditions diagnosed and suicidal ideations disclosed.
Judge McMeekan and the young person's lawyer agreed the young person needed to be housed in a secure residence which they "cannot escape from".
But an emergency request from their social worker had been turned down because such residences were "at capacity".
"It is my clear view that at this time [they] cannot be left in the community because of the dangers that poses to [their] wellbeing," Judge McMeekan said.
By September the situation had become "dire" and the young person was "engaging in high-risk behaviours" again, had absconded from the group home repeatedly and was self-harming.
Their lawyer told the court that "despite all the help" the young person was a "chronic high risk".
Judge McMeekan said the already "serious concerns" about the young person were further exacerbated because they had disclosed they were hearing voices.
The young person said they did not want to do what the voices were demanding but was "not able to control or stop those urges".
A further emergency request for a secure placement was denied.
In desperation, Judge McMeekan ordered a copy of the minute from that hearing be sent to OT's chief executive, Sir Wira Gardiner, Children's Commissioner Judge Andrew Becroft and Principal Family Court Judge Jacquelyn Moran.
A week had barely passed though when the situation became "even more critical".
The young person had absconded from their group home repeatedly and on one occasion police found them with an older man and had to handcuff them to take them home.
Days later the young person took off again and was found attempting to take their own life.
Their exasperated lawyer told the court he was "very concerned [the young person] will die" - despite the "skill and dedication" of the immediate support people.
"I do not think that is being over-dramatic - I share that view," said Judge McMeekan.
She "escalated" the case to OT"s "national office" and to its chief legal officer.
OT's response was that it was "best" for the young person to stay put - and again it said there were no more secure beds for the young person.
Judge McMeekan said OT was "endeavouring to see if they can place additional resourcing and supports" at the residence - but said it was "still under consideration".
One suggestion was a security guard to monitor the young person's room - which their lawyer suggested would only inflame the already scary situation.
He told the court he would "much prefer that there be a locked door" so he knew the young person was safe.
Their social worker also said the young person needed to be in a secure residence for their "safety and wellbeing" and told the court OT needed to "do more" to keep the troubled young person safe.
"[The lawyer] is concerned that every day [the young person] is not in secure care [they are] at risk - he notes every time [the young person] absconds [they are] harmed in some way.
"[The lawyer's] view is that OT have a statutory duty to keep [the young person] safe and to keep them alive - he has been wanting them to act for some time now in terms of an appropriate residence.
"The situation is chronic - it is dire. I share [the lawyer's] concerns that one morning we may wake up to hear of [their] death."
Judge McMeekan said the most recent absconding showed "exactly how dangerous" the situation was.
But her hands were tied and all she could do was "keep a watching brief" and encourage those looking after the young person daily to do all they could to keep them safe.
A Family Court registrar is now monitoring the case regularly and reports to a judge every few working days.
There is still no secure bed for the young person but a security guard has been contracted for round-the clock monitoring.
The young person's lawyer could not comment on the case.
OT would not answer specific questions from the Herald but provided a statement.
Deputy chief executive of care services Trish Langridge said OT had a "duty of care" for the young person.
"We are doing everything possible to ensure their safety and wellbeing needs are met," she said.
"The safety and wellbeing of all children and young people is the priority for OT and we take concerns of this nature very seriously."
Langridge said secure residential placements are provided for children and young people with "acute care and protection needs" where it has been determined that other care alternatives within the community or whānau are deemed "inadequate or inappropriate".
Judge Becroft told the Weekend Herald he was "hugely concerned and profoundly worried" for the young person.
After being alerted by Judge McMeekan he contacted OT "urgently" and requested "immediate action" to protect the young person.
He was keeping in regular contact with OT about his "ongoing concerns in relation" to the young person's care.
"I've been assured that there is a 24/7 safety plan in place to keep them safe - however we are not satisfied that the best care or social work has been provided to this young person," he said.
"These young people deserve the absolute best care we can all possibly provide them and the chance of a good life," Judge Becroft said.
"That has not been provided to this young person."
Are you worried about the safety of a child?
If you have concerns about the immediate safety of a child, call 111.
Alternatively contact your local police station - click her for a list.
Or, contact Oranga Tamariki, Ministry for Children on 0508 326 459 for advice or click here to visit the agency's website for more information.