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The move was recommended by an external review into an incident on Waitangi Day this year. A staff member at the residence near Christchurch was assaulted with an improvised shank during an attempted breakout that ended in a stand-off on the facility's gym roof.
The review said staff were suspicious something was up and acted on their concerns as best they could, even informing police. But the fact officers were present when the roof stand-off began was mostly due to luck as officers were not required elsewhere.
RNZ has obtained reports about the incident, revealing what happened at Te Puna Wai ō Tuhinapo (TWP), in Rolleston, and how Oranga Tamariki responded.
On February 6, five youths climbed onto the roof and were there for about three hours.
The attempted breakout was one of a number of incidents that preceded a hard-hitting review into New Zealand's youth justice facilities, which found the system had lost the public's trust.
A review by Safety Consulting Services Ltd found the assault on the staff member on 6 February, and an attempted second assault, happened during a planned operation by the youths to escape - possibly with the help of a former resident.
This was the first of two similar incidents this year at Te Puna Wai ō Tuhinapo, one of five youth justice residences in New Zealand. In June, four youths spent about 24 hours on the roof after one had earlier come down.
The Safety Consulting Services report into the February stand-off, signed off by its director Terry Johnson, said a staff member was assaulted as the incident unfolded.
It began when some youths refused to go to their rooms for bed.
"While attempting to barricade themselves inside [redacted] one rangatahi [youth] assaulted a staff member with an improvised shank, followed by an attempt on another staff member.
"The staff within the unit realised the seriousness of the actions against them, withdrew to the safety of the shared area and closed the unit wing doors."
An internal Oranga Tamariki report said the assaulted staff member was stabbed in the neck, piercing the skin in two places. They had since returned to work.
The Safety Consulting Services report said a youth attempted to assault a second staff member with the same weapon.
There was no contact with the weapon, although the hand of the youth holding it "contacted the face" of the staff member, causing no significant harm.
The youths left the unit by smashing a bedroom window, entered a ring road around the facility, and climbed onto the gym roof about the time police arrived at 8.30pm. Officers then set up a perimeter with the help of Te Puna Wai ō Tuhinapo staff.
The youths came down just before midnight. At the time RNZ reported this was "with police assistance". One of the youths was charged with assault.
Information from the facility's management said a former resident of the facility was to have picked up the escapees. The review said this was plausible, although no evidence was provided.
Te Puna Wai ō Tuhinapo staff were earlier that day suspicious something was brewing and had warned police.
The suspicious behaviour began when one youth was woken to attend a unit pool session, and was then seen walking around shaking the hands of other youths.
At the pool session, only two youths jumped in the water, which was unusual.
"The others were seen to sit and talk together or walk to the back of the pool fence."
When the session finished, the youths were seen whispering in small groups.
"There appears to be little doubt that the escape was pre-planned, possibly several weeks in advance, and involved the coercion or collaboration of rangatahi [redacted] to create a distraction."
The Safety Consulting Services report said the youths appeared to consider the possibility of assault, given they had armed themselves.
What caused it?
Safety Consulting Services identified eight causes or contributing factors, although four were redacted.
The four that were not were: The facility's layout; willingness of some youth to harm staff; poor security, which allowed the theft of a torch; and mixing among units, which gave youth the chance to organise the escape attempt.
Youths from different units mixed on 26 January when they played touch rugby and then used the swimming pool. Management decided to allow this to incentivise better behaviour.
A planned second "mixing event" on 3 February was canned after some youths were found possessing improvised weapons.
The review writers said they were particularly concerned about the units mixing.
"We understand that this is to encourage the right behaviour, however, unfortunately the full consequence of the rangatahi being able to use this to organise an event was not considered."
It was positive that staff recognised the youths were planning trouble, developed a plan to deal with the situation; and contacted the on-call manager to discuss concerns, as well as telling police.
One staff member from the night shift came in early, and another came in on a day off to boost numbers.
One of the key leaders among the youths involved was removed from his unit, which "appeared to cause considerable anxiety among the other rangatahi in the unit". That meant they weren't present when a sprinkler went off earlier in the day.
Safety Consulting Services found that was likely when the planned escape was meant to happen, but it was delayed.
"While ultimately the actions taken to prevent an event did not stop the rangatahi from taking their course of action, it's difficult to be critical with the mitigation put into place," the report said.
"When considering all the findings of this review the rangatahi seemed determined to follow through on their escape plan, no matter the barriers put up in front of them."
The report writer did not see any other options the staff could have taken, especially given the limitations on restraining or separating youths in the facility.
The review said an earlier police presence at Te Puna Wai o Tuhinapo might have disrupted the plan, but that's outside the control of the residence's staff.
"These two factors - the limitation on staff caused by regulations and the position of police to attend only once a crime has been committed - created a gap in prevention actions that was exploitable by rangatahi," Safety Consulting Services said.
"Without doubt, this event and the assault on staff highlights the need for reforms at TPW, but also considerations for Oranga Tamariki across its residences.
"Changes are required and must be introduced to ensure the safety of both staff and rangatahi, or the potential hazard of staff being assaulted to support an escape will continue to be a risk."
Addressing underlying issues demanded a "comprehensive approach" including improving infrastructure, enforcing consistent rules, and implementing effective strategies to manage high-risk young people.
The report said staff were limited in their search powers, so it was hard to detect contraband entering a facility.
The Safety Consulting Services report said staff made the right call in contacting police before the trouble started, although there was no set process for doing this.
There was uncertainty about when police could take over control of such incidents, and the quick response from police on 6 February was put down to luck, because officers happened to be free.
"There also appears to be frustration from the police that they are required to respond to so many events at TPW.
"While kaimahi [staff] at TPW feel they should be able to ring the police when they do not feel in control of the circumstances, including feeling unsafe, from our discussion with staff, most events tend to relate to rangatahi not following the rules or not being compliant, but where no significant crime has been committed.
"The view of the police is that YJ [youth justice] residences should be able to contain and handle the youth in their care without police intervention."
The report writer said police, however, had powers Oranga Tamariki staff did not. They recommended that the two organisations develop a memorandum of understanding outlining expectations when events happen at a residence.
A bread delivery truck that turned up as the stand-off began was also a risk.
It entered the facility because where it had parked was blocking police access, but if officers hadn't been on the scene so quickly the youths could have confronted the driver.
Another incident at Te Puna Wai o Tuhinapo
On June 24 another incident unfolded at the facility - which had capacity for 40 residents - when five youths made their way to the roof. It took almost a day before all of them came down.
Stuff reported they smashed their way into a roof cavity and threw objects at people; and that they were given fast food when they surrendered after this was promised during negotiations.
RNZ reported one staff member suffered minor injuries and was treated at Christchurch Hospital.
Oranga Tamariki general manager for youth justice residences Parani Wiki said the organisation accepted "there are issues facing its residences". That was why former police commissioner Mike Bush was brought in to temporarily take over their management and undertake a rapid review in June.
The results of that, released in September, found significant improvements were needed, and that the system had lost the trust of public, youth, and even staff.
Complaints about staff
During the three months of the review, Oranga Tamariki referred 28 complaints over staff conduct to police.
Wiki said Oranga Tamariki accepted Safety Consulting Service's recommendations about the February incident and "a work programme was created as a result of this".
"There were 30 young people in Te Puna Wai ō Tuhinapo and 19 staff members were working on 6 February, which is adequate for normal operations. We prepared for unplanned absences by having relief staff on call, as well as a casual workforce.
"Since 6 February a review of Te Puna Wai ō Tuhinapo residence infrastructure has been carried out and one unit has been hardened. This reduced the potential for rangatahi to break out."
There were "different factors" behind the youths getting on to the roof in the February and June incidents, she said, and Oranga Tamariki was "enhancing its standard operations procedures to ensure greater consistency of response across its residential network".
Mixing between units had started again. Associated risks were assessed and mitigated before it occurred.
Meanwhile, police and Oranga Tamariki had agreed a memorandum of understanding "with the purpose of ensuring an effective working relationship when assistance is needed during an event".
"The MOU sets out who leads in the event of an incident, something that differs depending on the type of incident," she said.
Each youth justice residence had built a relationship with its local police, resulting in an improvement in responses to serious incidents.
Wiki said staff were regularly trained to deal with incidents.
By Jimmy Ellingham