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Child, Youth and Family have admitted failing a 12-year-old girl who took her own life while in foster care after she claimed to have been sexually abused by a caregiver.
Krystal, whose surname is permanently suppressed, was found dead in her bedroom by her younger sister at their Auckland foster home on September 13, 2008.
She was one of eight children from a Northland family placed in Child, Youth and Family (CYF) custody in 2006 after their parents were arrested on drugs charges.
The kids went into foster care for two years before Krystal alleged on August 1, 2008 that she had been sexually abused by one of her caregivers and they were moved out.
Krystal killed herself after being sent to her room for fighting and being told she would not be allowed to stay if her behaviour continued, a coroner's finding released today says.
It slams the social welfare system for a series of failings by social workers after Krystal made the sex abuse claims.
Coroner Morag McDowell said Krystal's new caregiver, who had been looking after her for only three weeks, was not properly informed of her fragile mental state.
The troubled girl was not given the counselling or psychological support required, the report says.
Coroner McDowell outlined a number of "missed opportunities" to manage the girl's fragile mental state.
She expressed particular concern over the care plan given to her new caregiver, which was out of date and lacked detail about her individual needs and personal history.
"Ensuring that those people taking over the parental duties of a child have all the necessary information needed to provide adequate support tailored to that particular child is fundamental," Coroner McDowell said.
CYF said it fully accepts the coroner's findings into Krystal's death.
The social worker who produced the sub-standard care plan left CYF soon afterwards, while another social worker involved in the case subsequently received extra training.
"Put simply, we failed Krystal," CYF's deputy chief social worker Nova Salomen said today.
Since the 2008 death, the government agency had made "big changes" in the ways it works with abused children "to try and prevent a failure like this happening again", she said.
It has strengthened its care plans to improve key information provided to caregivers and implemented a specific assessment tool for social workers who work with children over the age of 12.
When a child or young person was evidentially interviewed, there were now clear guidelines that required specific social work actions.
CYF has also made changes to its information systems for social workers to highlight suicide risk and critical risk checks.
The agency said gateway assessments were now being used to assess the wider needs of all children in care. CYF has now automated the scoring on those tests to remove the risk of human error.
CYF apologised to Krystal's family for its failures, Ms Salomen said.
"We agree with the coroner that this case is a reminder for social workers to focus on the needs of children rather than being process-focused."