A public inquiry into the handling of the Tom Phillips case identified a series of failings by Oranga Tamariki. RNZ’s National Crime Correspondent Sam Sherwood takes an in-depth look at what went wrong.

Fronting a media conference inside Parliament, Oranga Tamariki (OT) chief executive Amanda Malu addressed a just-released public inquiry into the Tom Phillips case.

"This report makes for difficult and at times harrowing reading," she said.

"It identifies opportunities that were missed to keep these children safe."

She also addressed the children's mother and older siblings, saying the agency "did not listen in the way we should have, and this family deserved better from us".

The public inquiry comes two months after RNZ revealed a series of failings by OT in relation to its handling of Mustafa Ali before he was killed by his father. Ali was nine-and-a-half months old when he died in June 2024.

The review found several failings in the agency's response, including "minimal analysis" of risk and that the monitoring was not good enough.

It also said Oranga Tamariki staff reported there was a "lack of basic knowledge of practice and legislation" among some of the social workers and supervisors on site.

As earlier revealed by RNZ, both cases were managed by the same site for a time, but handled by different social workers.

In the wake of the Phillips inquiry, Malu told RNZ she has concerns arising from the report and will be "seeking answers to those questions".

"Given the inquiry report has only just been released, this is still in early stages, but my questions are likely to centre around the failings identified by the report."

The first report of concern

Phillips disappeared with his three children in September 2021 and did not return for 18 days.

Simon Moore KC's report says that on the morning of 30 September, a police officer called OT to make a report of concern. Those concerns included that Phillips had taken the children away for 18 days and that despite the use of search parties, Phillips and the children had been able to avoid detection for "some time".

Police also raised concerns about the living conditions in Phillips' Ōtorohanga home, and that he had not said anything about what happened while he was away with the children and that he had the potential to do it again.

That same day, police filed a written report of concern to OT. It said there were "no immediate concerns for the children's safety", but that police did have concerns regarding the last 18 days, including questions about where they had been staying and whether they had been "given their essential needs".

Police also said the home address was in a "very messy condition" and a "number of empty Vodka bottles" were found throughout the home.

Police spoke to OT for a second time on 1 October, noting they were not satisfied with the level of information and detail they had from Phillips, and intended to meet with him the following week.

The two agencies would not talk to each other again about the case until after the children disappeared for a second time more than two months later.

Sisters' concerns

Moore KC's report also goes into detail about concerns raised by the children's older siblings, named in the report as Anna and Jane.

They had lived with their younger siblings and Phillips, who was their stepfather.

On the evening of 1 October, 2021 (the day after Phillips and the children reappeared) Jane made an after-hours call to OT.

She insisted that OT should visit the children during the weekend, rather than the following week as had been scheduled.

Moore KC said Jane "expressed her deep concerns for the children's welfare and safety".

This included that the children had been taken away by Phillips for nearly three weeks with their older siblings and mother having "no idea where they were". Jane was also concerned about how the children presented when she visited him.

The call-taker told Jane, after speaking to a supervisor, that an after-hours safety check was not warranted.

Jane called OT's National Contact Centre the following morning asking for the agency to visit the children that day.

She said she had safety concerns for her siblings and was worried Phillips would disappear with them again, and that he would tell them what to say to social workers.

Jane asked the staffer if OT "would be held responsible if the children went missing again", and said she would continue to contact OT until something was done.

Two days later, Jane called OT again. This time she spoke to the local branch, telling them that she had been unable to visit her siblings as the gate to the Phillips' home was padlocked. She said during another attempt to speak to the children she was told they were too busy to come to the phone.

She also said Phillips told her she would only be allowed to visit the children on Wednesday and for only one hour.

"She was concerned that her siblings may be coerced into what to say and may forget everything if not spoken to soon."

Moore KC said that despite Jane's repeated concerns, OT did not meet with her at any time between 1 October to December 2021.

The agency also didn't take any additional steps to understand the "immediacy of her concerns or explore the foundation of them". Moore KC said they also didn't consider whether to treat Jane's concerns as a report of concern.

The affidavit

On 4 October, a social worker supervisor called Anna after she left a message.

The report says Anna wanted to talk about Phillips' character based on the years she had lived with him.

Anna made a statement, which Moore KC says is styled as an affidavit, and was affirmed by Anna before a Justice of the Peace.

The supervisor told Anna that OT were not the right people to use to submit the affidavit to the Court, and suggested she seek independent legal advice. Anna said she wanted OT to have a copy as part of the agency's assessment, and was given the supervisor's email.

Moore KC said the affidavit "contains details of her controlling and abusive experiences with Tom Phillips".

The supervisor who was overseeing OT's investigation told the inquiry she could not recall reading the affidavit.

After reading the affidavit as part of the inquiry, the supervisor said Anna's allegations against Phillips "read terribly". She said if the social workers read it at the time, it was likely they "would have challenged Tom" on the issues.

Moore KC said it appeared no one at OT read the affidavit.

"It is also notable in this context that despite the gravity of Anna's allegations around Tom Phillips as a parent, Oranga Tamariki did not treat her concerns as a report of concern under the relevant legislation."

A mother's concerns

The mother of the Phillips children told the inquiry she made several attempts to raise concerns with OT from September 2021, but said the area manager was "constantly unavailable".

Moore KC said OT had not been able to identify if or when the calls occurred, but records indicated they called her on 4 October to advise her of the report of concern and their investigation.

According to the record, the mother apparently confirmed she was happy for OT to be involved but said the children should not be in Phillips' care.

OT said they would make contact with the mother again to arrange a time to meet. This did not occur prior to the second disappearance.

On 5 October (five days after the children returned) a social worker and social work supervisor visited the children at Phillips' parent's Marokopa home.

Phillips, the children, his parents and two other family members were there.

Phillips told the social worker he "had no idea" a search and rescue operation was taking place while he was in the bush. He said the trip was "spontaneous but somewhat planned".

Phillips and his parents outlined his bush skills and experience. Philips said the disappearance was not connected to the Family Court proceedings, and said he "would never harm his children nor did he intend to".

He denied leaving the children alone at any point, and said he had no mental health issues, providing a medical certificate from his GP.

Following the home visit, OT recorded that the family "presented well".

"Tom did not present out of the usual, there were no obvious signs of drug use or mental health. Family was co-operative. Tom appeared to be upset when discussing the court process, but relieved that his family would support him and the children if the children needed to be placed elsewhere."

In the safety and risk screen, the social worker assessed the children as "safe" and said Phillips was "a very capable and loving father" who was "well supported by his parents".

The Family Court

On 6 October, OT provided an oral report to the Family Court.

The lawyer for OT said the supervisor had seen the children and found them to be "completely fine", and that there was "nothing particularly sinister about this trip, despite the unusual circumstances".

They also said that with the support Phillips had from his family "we're not sure if we have any further involvement or whether there is a need for further involvement for Oranga Tamariki here".

In response to a question from the Court as to whether there were any care and protection concerns, the supervisor replied: "no, no, definitely not on the surface of things".

OT did not reference, at any point in its submission to the Court, the concerns raised by Anna and Jane.

Jane called OT after the Family Court hearing, and said she didn't understand how the agency was saying the children were in "no real danger".

The supervisor told Jane that the Judge had made his decision.

"And nobody can change that. And [at] the end of the day it is the Judge's final decision."

Moore KC said given there was an active report of concern, OT could have taken further steps through the Family Court to ensure the best placement and safety of the children.

On 1 December, OT met with the children for individual interviews in response to the Police's initial report of concern. OT says the delay was due to restrictions imposed at the time in response to Covid-19.

The second disappearance

On 21 December, Police notified OT that Phillips had taken the children away again, and that they had not been seen for 11 days.

The social worker recorded "Police are not worried or have any concerns, they will just wait and see what happens."

Then, on the evening of 27January, 2022, Anna called OT asking what they were doing to find the children. She said she was concerned they were "not eating and not attending school". The staffer told her OT was still involved, and to contact the social worker during business hours.

Two weeks later, Anna called again and raised concerns about the children "being in the bush for eight weeks".

Anna's concern was passed to an internal OT staffer who responded to her colleague: "If the children are missing that is a police matter not an Oranga Tamariki matter anyway."

On 15 February, Anna called OT yet again. The file note said Anna had made "multiple attempts" to get her concerns on record after the children's second disappearance.

Jane was also repeatedly contacting OT.

On 10 February, 2022, she sent an email to OT's National Contact Centre with the heading "Report of Concern & Request".

In the email, Jane said she rang OT "numerous times" after the children first disappeared.

"No effort was made to establish a safer, stable living environment for them and I discussed the possibility of them disappearing again (as there was absolutely nothing in place stopping their father from taking them at any moment). I made it very clear I was concerned for their safety and wellbeing."

She said Phillips had "kidnapped the children".

"He has no right to do this. Don't forget there is a warrant for his arrest for failing to appear in court for charges relating to their first disappearance. So not only have they been kidnapped, they have been kidnapped by [someone] unstable - unstable because no one in their right mind would put their family (and especially first and foremost their children) through this a second time."

She said there needed to be "the utmost urgency placed upon this case".

"These children do not deserve this. … hose children did not ask to be kidnapped. They have missed Christmas, birthday, they have missed 63 days worth of opportunities to see their family and friends, to enjoy the Summer holidays as normal [children]. In all of their years this is the longest I have gone without speaking to them.

"Now I ask, what is being done? It is completely unacceptable that it has been 2 months since they were last physically seen and Oranga Tamariki needs to be doing more for these children. If anything has happened to those children, Oranga Tamariki will be responsible for not stepping in when they had a chance. I look forward to regular updates."

Two days later, OT confirmed receipt of Jane's email and noted it had been passed on to the relevant team. After getting no further response, Jane emailed again on 15 February.

She said that Phillips had recently tried to sneak into his parents' home and grab supplies. He asked them for money, and took food. She said the children were not with him.

"We have grave concerns for their safety and wellbeing. Where were they if they weren't with him? What is Oranga Tamariki doing to ensure their safety?"

On 22 February, Jane called again and spoke to the assigned social worker. After the call, the social worker followed up with Phillips' mother and Police regarding his visit to the family farm and requested a general update.

In her email to police, she said Jane was "frustrated that 'nobody is doing anything' and requested confirmation that police were 'still following up on leads'".

Report of concern closed

On 21 February, 2022, OT staff met to discuss the case. Among the matters discussed was whether the children were in need of care and protection. The social worker and social work supervisor confirmed they did not have concerns.

"Tom is in breach of the Contact order in favour of the children's mother, however this is a Family Court matter and we do not have any place in that matter.

"Whether there is any work for us with these children. It was agreed that there is not. Therefore, [the social worker] will prepare the file for closure."

Moore KC said some OT staff maintained to the inquiry that they could not be "actively involved while the children were missing".

OT told Phillips' mother on 24 February about closing the report of concern. Phillips' mother told OT she was "sure that he [Phillips] is still in the bush".

"We do not have any concerns for the children at all," she said.

The following day OT emailed Jane to say the file would be closed.

Moore KC said that at no point from 30 September, 2021 to 25 February, 2022 did OT meet with Jane, Anna or the children's mother.

On 25 February, police emailed OT saying they did not know where Phillips or the children were.

"We do follow up on information that is provided for us, but at this stage that has not assisted in locating them. We are monitoring any changes, but we [are] still conscious that there are no concerns for the children. We are aware that Thomas did return to the family home around midnight a few weeks ago, indicating that the children are okay."

OT replied confirming it was closing its file.

OT 'minimised' concerns raised

Of the 41 findings made by the inquiry, 13 related to Oranga Tamariki.

Moore KC said OT did not take all practicable steps to fully understand concerns raised by police or the maternal whānau after the first disappearance, and should have more carefully considered Phillips' mental health.

He said OT's initial response to the report of concern was "appropriate and reasonable", but found the agency did not adequately engage with, and did not accurately inform the Family Court at the hearing in October 2021.

In relation to the agency's work after they disappeared a second time, Moore KC said OT should not have closed the report of concern in February 2022.

"It was the role of Oranga Tamariki to continue to investigate the reports of concern of Police and Jane, and the concerns raised by Anna.

"Those concerns identified current and ongoing risks to the safety and welfare of the children. The absence of the children itself presented a care and protection issue."

Moore KC also said OT held information that "should have led it to have grave concerns for the children's continuing safety during their concealment".

The agency also continued to minimise the concerns of the sisters after the second disappearance, Moore KC said.

A deputy chief executive of OT told the inquiry Jane's concerns should have been treated as a report of concern, and an initial assessment should have been undertaken.

Other findings included that OT should have informed Police of the risk to the children, and that the agency missed an opportunity for engagement with the Family Court by "wrongly" closing its report of concern in February 2022.

Moore KC said that from August 2023, OT treated the children's disappearance as a risk of harm, however this should have happened from December 2021.

He said that from August 2023 OT took "appropriate steps" to prioritise the welfare of the children.

Oranga Tamariki 'seeking answers'

In response to questions from RNZ about the Phillips case, as well as the death of Mustafa Ali, Malu said on Friday OT had made several changes at the site since the period focused on by the public inquiry.

They also conducted a rapid practice assessment into its involvement with Ali and his whānau.

Malu confirmed the Phillips case remained "connected to the local site" throughout the period covered by the Tom Phillips inquiry.

"Additional cross-agency and organisational support was put in place from 2023, and Oranga Tamariki subsequently established a dedicated regional team to manage the case.

"This was overseen and supported by senior staff from across the organisation."

Malu noted that the inquiry "commended the actions of staff at this same site from 2023 onwards in relation to the disappearance and recovery of the Phillips children".

"However, I have concerns arising from the findings of the public inquiry, and as the new chief executive I will be seeking answers to those questions."

Malu said given the inquiry report had only just been released, this was still in early stages.

"But my questions are likely to centre around the failings identified by the report."

She said it would not be appropriate to comment on individual staff members while those inquiries were ongoing.