Boy's death blamed on CYF errors

By BRITTON BROUN - The Dominion Post


Hoki Thompson still cannot understand why her 14-year-old charge Denbora Oum took his own life.

The slightly built Cambodian boy, who was under Child Youth and Family care, had been happily living with Mrs Thompson and her husband Bill at their Porirua foster home for three months.

She had looked after troubled children for 30 years, but was devastated when she came across Denbora's body on the porch of her house on June 28, 2005.

"I felt so guilty, I felt like I hadn't done enough," she said yesterday.

"I've had a lot of suicidal kids but you know they're like that and you see the signs. With poor Denbora there was nothing. It's such a shame. He just wanted to go back to school ... and back to his mum."

Mrs Thompson remembered Denbora being quiet but smiling, a mischievous prankster who always followed her around.

But he had been in and out of CYF care since he was an infant, between living at home with a violent mother and a brother who physically and sexually abused him.

Mrs Thompson said she was told nothing about his suicide risk.

Denbora was born in New Zealand, one of five children in a Cambodian family. His father died when he was four and he and his brothers and sisters were raised by their mother.

Wellington coroner Garry Evans said CYF had categorised Denbora as a high risk of suicide in 2001. Mr Evans found communication and system failures at CYFs Porirua office had contributed to Denbora's death.

In 2002, counsellor Steve Phoenix said the boy's problems stemmed from his family and intervention was needed to change their behaviour. If nothing was done Denbora may attempt suicide, he warned.

Mr Evans said 11 different social workers had dealt with the family, but there was minimal exploration of family relationships and history.

No-one had in-depth knowledge of Denbora's life, while plans to help the Oum family fell short.

Mr Phoenix's clear warning should have been acted upon, he said. "Implementation of the plans would have required good communication and engagement by the social worker with Denbora, his family and the other professionals involved ... [but] there is little evidence of good engagement."

Failures included:

Language and cultural barriers and a negative perception of Denbora's mother saw her become isolated from the CYFs process.

CYFs paperwork was lacking, with important information and several risk assessment reports not put in Denbora's files.

Pressure in the Porirua CYFs office was "intense" because of understaffing. When Denbora died, his social worker was on stress leave, possibly delaying him going to a new school.

The work culture in the office was more about meeting "computer-based key performance indicators instead of more in-depth work with the children and their families".

Mr Evans recommended CYFs develop a risk assessment and management plan for every child in their care; that work systems focus on the holistic care of children; and records be thorough, regularly updated and stored electronically and on paper.

CYFs chief executive Ray Smith said Denbora's death was "an immense tragedy" but there had been great improvements since.

There was now better supervision and support for social workers, more training, and more effective risk management.

"This has resulted in major improvements to the way our sites, including the Porirua office, are operating and a significant staff culture change," Mr Smith said.

CYFs had also reduced the number of unallocated child cases, from 3482 in 2004 to 69, and improved its suicide prevention programmes. The agency would also look at Mr Evans' other recommendations.