Three children have died in state care in the Bay of Plenty in the past five years - one by accident in 2017, one by suicide in 2019 and a third of natural causes in 2019.
They were three of 27 children who died while in state care since Oranga Tamariki's inception in 2017.
Of the 27, 15 died from natural causes, five by suicide, another five from accidents, and two as a result of child abuse, homicide or manslaughter.
Whānau Ora Commissioning Agency chairwoman Merepeka Raukawa-Tait said the death of a child was always an awful time for families.
"When a child dies while in state care, I consider that a double tragedy," she said.
"State care is considered safe care. A child has been taken from their family because the home environment is supposedly unsafe.
"Children should not be dying of suicide, accidents or homicide in well-monitored state residential care and homes."
Raukawa-Tait said the best solution to ensure children were kept safe was to ensure they were loved and cared for in their own homes.
"Invest in supporting the parents to make any necessary changes.
"Understand what's going on in the home and ensure wraparound services are provided. Get in early and seek help from the wider family as well."
The number of children in the care and protection or custody of Oranga Tamariki in the Bay of Plenty region has mostly fluctuated around 500 over the past five years.
In 2017, there were 524; in 2018, there were 554; in 2019, there were 518; in 2020, there were 511; and in 2021, as of June 30, there are 391.
Oranga Tamariki was formerly called Child Youth and Family until the Ministry for Children underwent a major overhaul in 2017.
In 2016, the Herald reported 77 children in state care had died in state care across New Zealand in the previous 15 years.
The information about deaths in state care since 2017 was revealed following an Official Information Act request to Oranga Tamariki.
University of Auckland psychology lecturer Dr Shiloh Groot said mental distress could look very different for different people.
"I'm not a clinician and I would be averse to pathologising young people in state care," she said.
"But I do think that the traumatic nature of being forcibly removed from whānau into state care impacts young people psychologically, emotionally, and spiritually.
"Any deaths — whether it's one or more — in state care are an immeasurable and unacceptable loss of a young person's life."
Children in state care identified with a suicide risk have an alert placed on their file which allows support staff to help, deputy chief executive for children and families Glynis Sandland said.
A risk assessment programme has also been set up to support social workers by providing access to specialist advice and support around managing suicide risk too.
"A death of any child is a distressing occurrence," Sandland said.
"We have a number of systems in place to ensure appropriate support is offered and extended to those impacted by a child's passing.
"Towards Wellbeing is a risk assessment and monitoring service that supports social workers by providing timely access to specialist advice and support around identifying and managing suicide risk."
Ngāi Te Rangi chief executive Paora Stanley said the deaths were difficult to act on because one couldn't blame an agency from someone dying of natural causes.
He said the uplifting of children impacted families in a range of ways, such as not letting the child visit other members of the family or if mothers who had children uplifted did not register subsequent children.
"The rationale for that is that people say they need to be below the radar," Stanley said.
"They don't want OT to come and take that child away from them. That sets a really dangerous precedence. It has the reverse effect of what you really want it to be."
It comes as a review released this morning found Oranga Tamariki was a "weak, disconnected and unfit" agency and the Government said it would stop child uplifts.
The Government accepted all 25 of the panel's recommendations to "fix" Oranga Tamariki.
Established by Oranga Tamariki Minister Kelvin Davis in January, the board was damning not just of the child protection agency but the Crown for assuming its role in the first place.
"The Crown has assumed the lead role in supporting tamariki and whānau without really knowing how to be effective in this," report authors said.
In doing so, the Crown had "undermined the role of communities and particularly of hapū and iwi in leading their own communities".
The board called for resources and decision-making to be devolved to Māori collectives and communities, with a clear pathway for this to happen.
WHERE TO GET HELP
• Lifeline: 0800 543 354 (available 24/7)
• Suicide Crisis Helpline: 0508 828 865 (0508 TAUTOKO) (available 24/7)
• Youth services: (06) 3555 906
• Youthline: 0800 376 633
• Kidsline: 0800 543 754 (available 24/7)
• Whatsup: 0800 942 8787 (1pm to 11pm)
• Depression helpline: 0800 111 757 (available 24/7)
• Rainbow Youth: (09) 376 4155
• Helpline: 1737
If it is an emergency and you feel like you or someone else is at risk, call 111.