Introduction

On the night of 3 December 2001, Olympia Jetson and Saliel Aplin were killed. They were aged 11 and 12. Their mother's then partner, Bruce Howse, has been convicted of their murder and is now serving a prison sentence of 28 years.

Child, Youth and Family has had an involvement with the Jetson/Aplin/Howse family since the late 1980s. Departmental records refer to both Olympia and Saliel as well as to Ms Aplin's children from previous relationships and Mr Howse's children from previous relationships. At the time Olympia and Saliel died, the Department had an open case in respect of Olympia.

Review

Given that the Department had worked with this family for a considerable time and the nature of its involvement prior to the childrens' deaths, I engaged reviewers to look into the case and report to me.

I engaged John Morrison, an independent barrister, assisted by Tuakeu Pilato, a Child, Youth and Family manager, to conduct the review. The review process was delayed at the request of the Crown prosecutor responsible for the murder trial arising from the girls' deaths. Accordingly, the review was carried out between 17 December 2002 and 18 March 2003. Completion was delayed by two weeks due to the illness of one of the reviewers. The review was based on an examination of Departmental records and interviews with current relevant staff.

This review is not an enquiry into cause of death or responsibility for death. That is for the prosecuting authorities to determine. The purpose was to examine whether Departmental policies and procedures had been followed, whether the practice had been of a good standard and whether any identified gaps in practice could be addressed.

The review has now been completed. This report is a summary of that review. I am satisfied it contains the key findings of that report while maintaining the privacy of those involved. It is already a matter of public record that Olympia and Saliel were the children of Charlene Aplin and that Bruce Howse murdered them. All others involved will not be named in this report.

Context

Legislative

Child, Youth and Family operates within the legislative framework of the Children, Young Persons and Their Families Act 1989. Broadly, that Act declares the child's right to grow up in a safe and nurturing environment. In the first instance, that environment should be provided by the child's family but, if it is not, the State asserts the right to intervene, to ensure that the child's rights and interests are safeguarded. The State intervenes formally through the Chief Executive of the Department of Child, Youth and Family Services and, practically, through social workers employed at various offices throughout New Zealand, funded by Government.

In practice, balancing available resources against need requires social workers to make judgements on priorities on a daily basis, assisted by their supervisors. To best ensure efficient, timely and successful interventions by social workers in the lives of children and their families, Child, Youth and Family has developed policies and guidelines to direct and assist social workers in the discharge of their duties. These policies and guidelines are set out in a Handbook, available on-line to all staff.

The reviewers have advised me that they believe the Handbook is daunting in its volume and that adherence to every detail in it is beyond what could be reasonably expected. Whilst I acknowledge their view on this, I do not agree. These policies and guidelines are in a Handbook that is easily accessible both electronically and in hard copy. An in-depth knowledge of the whole Handbook is never needed at once. Its size is immaterial so long as there is a quick reference index to direct workers to relevant sections, as required. I would also note that some policies go to the "heart' of child protection work while others are more administrative or ancillary in nature.

Administrative

Over most of the period of the Department's involvement with this family, social work services have been provided from the Masterton office. Until 2001, Masterton and Dannevirke staff reported to an Area Manager at Palmerston North, with a Site Manager based at Masterton taking responsibility for Dannevirke as well. From July 2001, the Site Manager's position was disestablished and a Wellington based Manager took over responsibility. The Masterton office, dealing with what it considered to be endemic abuse of children in the Wairarapa, as well as the aftermath of two other child deaths, felt under-resourced not only in terms of experienced social workers but in terms of administrative support. Within the Masterton office, care and protection matters were dealt with by two teams; a roopu team for notifications relating to children or families of Maori ethnicity and a general team for other notifications.

I want to acknowledge the difficulties created for staff as the management arrangements for Masterton have changed over recent years. The disruption to management lines and accountabilities has had a destabilising effect on an office which has had to deal with several highly publicised, violent attacks on children. However, I question the degree of effect this has had on professional practice. Social work practice occurs within a range of management arrangements and a standard should be maintained, regardless of reporting lines.

Two general points

Recording

Overall, the extent and detail of record keeping in this case was comprehensive and extensive.

Supervision

Supervision of the social worker by the supervisor in this case was regular, active and recorded.

Chronology and comment

Records of the Department's involvement with the family begin in 1989 and can be considered as being in three phases. It is important to note here that the Department was not involved with the children because they were causing difficulties to their parents. The Department was involved because the children were living in potentially unsafe environments. It was a struggle to impress on the mother the need to protect her children and that failure extended over time as she moved from one violent relationship to another.

The first phase - 1989-1993

Between 1989 and 1993, the Department was involved with the family regarding the sexual safety of the children. The reviewers have concluded that, in this phase of the Department's involvement, an appropriate investigation was undertaken and conclusions reached.

I would add to this that the social workers came to their conclusions, at that time, in consultation with several other professionals who were involved with the family. Police, Health Professionals and Panel members all played their part in this phase.

The second phase - 1994-1999

This was the most substantial phase of the Department's involvement with the family. It coincides with the mother ending one relationship and developing one with Bruce Howse. Disclosures of sexual abuse by another party were made to their mother by two of the children but clear disclosures were not then made to Police.

Domestic disputes were frequent and explosive. Social workers found the children inadequately cared for and the subject of physical abuse by Bruce Howse. This resulted in Olympia, Saliel and their siblings being placed with their maternal grandparents. A family group conference found the children were in need of care and protection and Child, Youth and Family applied to the Court for Custody and Guardianship Orders. This plan was followed. Olympia, Saliel and their siblings were placed in the custody and additional guardianship of the Chief Executive.

Four of the children were returned to their mother's care, and that of Bruce Howse, in November 1999.

Over a 5-year period, Child, Youth and Family staff received extensive intra-family cross-accusations. Social workers worked closely with other agencies and persons to protect the children and assist the fostering of a nurturing family environment. Extensive counselling and other services were provided. Appropriate consultation and the cooperation of a significant number of professionals resulted in the agreed conclusion that the children should return to their mother's care. That was not an easy conclusion to come to and one that the social worker was reluctant to agree to. She was concerned for the welfare of the children in a household that included Bruce Howse. However, Charlene Aplin and Bruce Howse were a unit. They accepted, even sought out, counselling and other guidance for parenting. They knew of and sought out Child, Youth and Family's assistance with the children.

The reviewers have stated "That the children would be returned to their mother's care was almost inevitable.' Both Charlene Aplin and Bruce Howse agreed to participate in parenting and anger management programmes in order to improve their parenting abilities. Reservations the social worker had were overcome, if not altogether satisfied, and return of the children to their mother's care was endorsed by significant others and agreed to by the Family Court.

The involvement of Child, Youth and Family in the period 1993 to 1999 was extensive. Involvement that began with notifications about the safety and welfare of the children was sustained by allegations and counter-allegations from within the family. This five year period of Child, Youth and Family's involvement shows evidence of careful cross-agency consultation and a reasonable standard of judgement.

The third phase - April 2000 to 4 December 2001

This phase started in April 2000, with notifications and interventions relating to or arising out of changes in the relationship between Charlene Aplin and Bruce Howse and a concern for the safety of the children. Police were called out to the Aplin/Howse home in April 2000. A domestic violence incident had occurred. Social workers visited the home within the timeframes required by Departmental policy and found no one there. They made several attempts to find the family, through contacting neighbours and local schools. All attempts to locate the family were unsuccessful. The family came to light in June 2000. They were now living in Woodville. The family moved back to Masterton in August 2000. All of the children were seen by a social worker who was satisfied that they were safe at that time. The supervisor, having regard to the nature of the notification, previous knowledge of the family and other notifications to be followed up, closed the case in September 2000. The reviewers have come to the view that, in the circumstances, this was a judgement the supervisor was entitled to make.

Almost a year later, on 3 August 2001, the Deputy Principal of Olympia's school made a notification to the Department, alleging suspected sexual abuse of Olympia by Bruce Howse and making reference to another sibling as well. This was immediately responded to by a social worker. That social worker made contact with the school that day and went on to the maternal grandparents' home, where she found Olympia and her mother. She arranged for Olympia to stay there over the immediate future. The other child was already in a safe place.

When the social worker went to the home to speak to Olympia about the allegation, after the weekend, she was told that Olympia had been overheard telling a sibling that the allegations she had made against Bruce Howse were false. Olympia confirmed this to the social worker in the presence of her grandmother. She retracted the statements she had made because, she said, she had wanted to get back at Bruce Howse because he had killed the family cat and because he refused to give her money for books. Olympia seemed relieved as if having unburdened herself. The social worker concluded that the retraction, and the acknowledgement of having lied, were genuine. She spoke to the other sibling who denied the allegations, and she was satisfied that this child had not been abused. As a result of the retractions, the social worker did not proceed with the intended evidential interview of Olympia. She made no further investigation or assessment.

She did not refer the matter to the Serious Abuse Team (SAT) supervisor in the Police, under the joint Child, Youth and Family/Police SAT protocol. Instead, in consultation with her supervisor, the conclusion was reached that the case should be closed, subject to referral to the Care and Protection Resource Panel and its endorsement of that conclusion. The social worker then spoke to Charlene Aplin and Bruce Howse, telling them of the allegations and retraction and agreeing to Olympia returning to their care. She stressed there must be no consequences for Olympia as a result of her telling lies and they assured her there would be none. The social worker recorded that she was unable to substantiate the allegation. Later, the school principal contacted the social worker, asking her to talk to Olympia about telling lies.

On 3 September 2001, notes made by Olympia in her school book were forwarded from her school to the social worker. Those notes talked about rape by Bruce Howse, being "felt' by two other men and being given a hiding by another man. It appeared to the social worker and the supervisor that the information referring to Bruce Howse was a repeat of the same information as that previously discussed with Olympia and retracted by her.

The reference to one of the men appeared to be historical, referring to an incident that had been investigated some 10 years earlier. The disclosures of "being felt' and of being "given a hiding' were taken as "new information', but as not necessarily giving rise to a new or immediate concern for Olympia's welfare. This was to be a matter for subsequent inquiry and assessment. The supervisor recorded a note to the social worker to "discuss with mother Olympia's "writings' and perhaps referral for counselling.'

Meanwhile, the 3 August 2001 notification was discussed by the Care and Protection Resource Panel on 12 September 2001. There is no record to show conclusively whether or not the 3 September school book entries were part of that discussion. The Panel recommended Olympia be referred for counselling.

The "new information' had still not been investigated at this time. The social worker went on leave and, when she came back, had other, more pressing cases to attend to. Nevertheless, she did not lose sight of the new information and the need for it to be enquired into and assessed. She attempted unsuccessfully, to contact the mother by phone and home visit. On 16 November 2001, the social worker wrote to the mother asking her to make contact, saying she had some "new information passed on to me which I need to discuss with you.' Meanwhile, the case had been closed on the electronic record system on 5 November 2001, as previously agreed by the supervisor.

When Charlene Aplin acted on the letter and made contact with the social worker on 3 December 2001, they had a telephone conversation about the further information.

Olympia and Saliel died that night. Bruce Howse was later convicted of their murder.

Comment on practice in the third phase

The reviewers have formed a view on practice during this phase and I include my own views alongside those.

These can be grouped into eight practice issues.

1. Immediate safety of the child

The first comment on practice is a positive one.

When the social worker received the 3 August 2001 notification from the school, she acted immediately. She went to the school, found that Olympia and her mother were at the maternal grandparent's home, went there and arranged for Olympia to stay there for the weekend. She interviewed the other child included in the notification and ascertained she was safe.

It is my view that the social worker carried out her job well at this time. She responded immediately. She took action to satisfy herself that Olympia and her sibling were safe.

2. Need for separate notifications for siblings

The notification of 3 August 2001 came from Olympia's school to Child, Youth and Family's national Call Centre. It was logged and sent on, electronically, to Masterton office. The information concerned suspicions of sexual abuse of Olympia.

The reviewers note there should have been two cases registered for consideration, not one containing information on two children. I agree. This recording error could have resulted in one child becoming "lost' in information about another child. Fortunately this did not happen. The circumstances of the second child were enquired into. The policy that requires recording of each child separately is designed to ensure a separate and full investigation for each child.

It is my view that the Call Centre, when taking the 3 August 2001 information on two children, should have specified this as two separate notifications. They were not. They were rolled together. Masterton site staff had the opportunity to correct this by altering the electronic record on receipt but did not.

3. New information not recorded or entered as a notification

The case was closed on 5 November 2001 although there was still outstanding "new information' of 3 September 2001, yet to be investigated. At the very least, the new information should have been entered onto the record and the case kept open.

It should have been entered as a separate and new notification. Neither course was taken. The reason for this was the social worker and supervisor were uncertain what importance or significance to attach to the new notification.

It is my view that the information received on 3 September 2001 should have been entered onto the case recording system as a new notification. If this had been done, there would have been an open case that would have required a considered decision by the social worker and the supervisor, and reference to the Care and Protection Resource Panel, before closure of the case.

4. Consultation with the Practice Manager

It is the role of the Practice Manager to oversee practice quality and to assist in resolving difficulties or uncertainties that might arise in the course of a case. To be able to fulfil that role they must be consulted. In this case, the supervisor did not consult the Practice Manager.

The reviewers have come to a view that uncertainty about the new information should have triggered third party consultation with the Practice Manager. I would go further than the reviewers. The social worker and supervisor were unsure about the significance of the new information. This demanded that they consult with their Practice Manager. Practice Manager positions were established for the specific purpose of providing leadership in social work practice. Uncertainty over a social work issue should have led to a meeting with the Practice Manager for case consultation and direction.

It is my view that consultation with the Practice Manager should have occurred.

5. Serious Abuse Team Protocol (SAT Protocol)

Departmental policy requires that in matters of sexual or physical abuse, reference will be made "as soon as practicable' to the Serious Abuse Team supervisor. This is a specified member of the Police. The protocol also states:

"Reports of abuse made by a child must be investigated'

"Should a child recant, a full investigation shall continue to be made.'

The reviewers have stated that "Olympia's prompt retraction of the allegation of abuse, seemingly genuine to an experienced social worker, encouraged a conclusion that there was nothing to investigate.' This was agreed to by her supervisor.

The Serious Abuse Team protocol was not complied with in respect of the 3 August 2001 notification nor of the 3 September 2001 information. If the "new information' was part of the 3 August 2001 notification, it called into question the retraction. If it was a new notification in its own right, it should have been investigated and referred to the Serious Abuse Team supervisor.

The Serious Abuse Team protocol is one of the most significant policies in child protection work. It exists to guide social workers through investigations, alongside Police.

It is my view that the failure to follow the Serious Abuse Team protocol on 3 August 2001 and 3 September 2001 were serious breaches of Departmental policy.

6. Risk assessment

The Department has developed a system of tools to help social workers work out the degree of risk to a child. Departmental policy on the use of the tool requires that it be used -

- if abuse is substantiated; or

- if abuse is not substantiated but there is a need to assess the elements of risk; or

- if decisions are to be made that require a re-assessment of risk.

Abuse was not substantiated in this case. However there was a need to assess the elements of risk. For this reason, the reviewers have formed the view that the social worker and supervisor should have consciously considered using the risk assessment tool to consider the elements for risk before closing the case.

I have considered this and agree with them. It appears that, having not substantiated abuse, they did not turn their minds further to the requirements of the policy. The circumstances obliged the social worker and supervisor to at least consider applying the tool to assess risk.

It is my view that the social worker and supervisor should have applied the Risk Estimation System to ascertain the level of risk that remained after the retraction was made.

7. Communication

Whenever a notification of abuse is received, the first step is to secure the safety of the child, before beginning any investigation. This recognises that the very process of investigation, making enquiries and gathering information, may endanger a child. The process of inquiry, the asking of a question, conveys the issue at the heart of the inquiry. Care must be exercised when communicating the reason for the inquiry.

In this case, while the new information was being investigated, either Olympia needed to be removed from the home or the inquiries made in such a way that would not inform Charlene Aplin or Bruce Howse of the substance of it. On 16 November, the social worker sent a letter, referring to new information. On 3 December, Charlene Aplin contacted the social worker. After the deaths of Olympia and Saliel, Charlene Aplin was reported to say that the letter had been intercepted by Bruce Howse. The social worker was cautious in what she said during that phone conversation with Charlene Aplin. In fact, Charlene Aplin is reported as saying she was not told what the new information was. Nevertheless, it was reasonably foreseeable that Bruce Howse could read the letter, interpret it as referring to him and depending on his state of mind, put the children at risk.

I have considered this point with great care. The reviewers have come to the view that it was "unsafe practice, and unnecessary, to send a letter to the home in which Bruce Howse resided, referring to "new information.' I agree with their view.

This does not mean that social workers should not be free to communicate with their clients and others by letter, or e-mail, if they wish, when there is no risk associated with sending such a letter. For example, social workers frequently write to their clients in care, making times to meet with them to discuss their plans. However, knowing that Bruce Howse lived there, that he was violent and that he was being accused of sexually abusing these girls, there was always a risk that he might open the letter. The issue is that it is potentially dangerous to write to a client or their parents or guardian during the course of an investigation because there is always a possibility that the letter will be opened by someone who could put the child at risk.

The social worker needed to investigate the new information. She made a judgement to contact Charlene Aplin by letter. It is my view that this letter, worded as it was, should not have been sent.

8. Familiarity

There is one final practice issue, raised by the reviewers, which is a general comment on the Department's involvement over the entire case.

It is called familiarity.

There is no doubt the social worker and supervisor were very familiar with the Aplin/ Jetson/Howse family. There had been continuity of involvement since at least 1994. That familiarity included knowledge of allegations and counter allegations and retractions over several years.

The reviewers state that the social worker did not take Olympia's 3 August 2001 retraction at face value. She concluded that the retraction was genuine and that conclusion was endorsed by the supervisor.

The practice issue is whether the familiarity of the social worker with the case influenced her response to the allegation.

Child Protection work in Child, Youth and Family is built on a series of checks and balances. The social worker forms a view. That view is discussed with and tested by the supervisor, with the Practice Manager available for consultation. A range of other views, based on knowledge and experience are brought to the table by the members of the Care and Protection Resource Panel.

It is of serious concern to me that the checks and balances referred to above did not counteract the consequences of familiarity in this case.

It is my view that there was a lack of rigour applied to the decisions made in the most recent contacts in this case and that this may have arisen from the long, familiar relationship between the family and those who were involved with them.

The normal checks and balances of the care and protection system, all of which need to be triggered by a social worker and considered by a supervisor, did not operate effectively in this case.

Shannon Pakura

Chief Social Worker

2 April 2003