Staff shortages at south Auckland's youth justice facility after workers were stood down over allegations of a fight club are partly to blame for a rooftop stand-off, a review shows.
A group of teenagers climbed on to the roof of Korowai Manaaki in Wiri on 1 July 2023 and some stayed there for more than a day.
Five remained after midnight, and at the time, Oranga Tamariki said three came down at 6.30pm on 2 July, before the remaining two followed at 11pm.
The situation was resolved partly because of an offer of fast food to the young people.
RNZ has obtained an internal Oranga Tamariki "post-incident debrief" in which staff shortages at the facility were cited as one factor in what happened.
There was also confusion among staff and emergency services about who would take the lead in responding to the incident, and no clear communications plan or coordination.
New Zealand has five youth justice facilities. They have been in the spotlight in recent years due to allegations of staff behaviour, escapes and rooftop stand-offs.
Oranga Tamariki national director of youth justice care and protection Iain Chapman said there were 15 rooftop incidents in 2023, mostly in the first half of the year. There have been none so far in 2024.
Chapman pointed to the review of the residences last year from former police commissioner Mike Bush after the fight club allegations were exposed. Since then, Oranga Tamariki had "worked to improve our residence recruitment, leadership and infrastructure".
"However, the reality is youth justice residences are unpredictable environments. While we must be tenacious in driving change, we are aware that the risk of disorder will always remain a challenge."
Staffing concerns outlined
At a debrief meeting into the Korowai Manaaki incident, Oranga Tamariki's Patrick Bain cited "lack of staff who had been stood down due to video footage (11-14 staff down)" as a factor on the weekend of 1 and 2 July.
The staff were stood down after video footage taken by an Oranga Tamariki worker was posted to social media in June 2023 showing two teenage boys attacking each other at the facility. The pair were egged on by fellow residents.
Chapman said the stood-down staff were subject to "ongoing employment matters" so he could not comment further.
Another Oranga Tamariki staff member, Parani Wiki, also mentioned low staff numbers on the July weekend, saying there were a "number of" unplanned absences, while casual workers were not available.
This placed those working there under strain.
Chapman told RNZ five youths were initially involved in the incident. Four "accessed the roof cavity", before two more joined. Of the six, five climbed down on 2 July. It was unclear when the sixth came down.
It was reported at the time that some had weapons, and Oranga Tamariki said they caused significant damage, including to the roof, ceiling cavities and security cameras.
Two staff members were injured.
In the debrief, released under the Official Information Act, Oranga Tamariki redacted its summary of the incident itself, citing a clause of the act that allowed information to be withheld to "prevent the disclosure or use of official information for improper gain or improper advantage".
However, parts of the notes from the debrief meeting reveal the youths broke out a window. Facility residents had been playing PlayStation and the staff members present had "split views as there [are] different situations on the floor, whilst being short staffed".
An incident escalated, so a staff member was swapped out to change the mood. But the situation worsened.
Staff thought the breakout was planned, the document said.
Some of the debrief's conclusions were redacted, although the need for more training and improved infrastructure at the facility were not.
The resilience of staff and their sense of responsibility in supporting each other was praised, as was having Fire and Emergency workers present for advice and experienced staff dealing with police. Senior managers were also present.
But "staff unplanned absences" affected what happened, and there was no clear communication plan or "coordination with everyone in the same room working together".
There was initial confusion about who was going to be the incident controller, with police onsite not wanting to take the lead, and the presence of multiple police units escalated anxiety and tension among the youths.
Police did eventually take the lead on the Sunday, "when things got heated", the debrief said.
Its final recommendations repeated the need for better training and communication planning, infrastructure improvements and adequate staff levels.
Chapman said Oranga Tamariki had made progress on the recommendations.
It had undertaken "significant work to identify areas of vulnerability and strengthen infrastructure at Korowai Manaaki since July 2023".
"This includes the targeted hardening of areas throughout the residence."
Oranga Tamariki was confident it had improved its communications and coordination systems for such incidents, Chapman said.
That included training staff on the system that allowed for "effective cross-agency coordination", known as CIMS.
Chapman said Oranga Tamariki had undertaken a recruitment campaign, improved staff inductions, and focused on getting the right level of staffing in relation to the number of youths.
"The incident at Korowai Manaaki was high risk and evolved incredibly quickly. The dynamic nature meant staff were making fast decisions, taking the safety of everyone on the site into account."
Oranga Tamariki chief executive Chappie Te Kani confirmed cuts to the agency announced on Wednesday would not affect frontline workers, so improvements were not affected.
Two incidents in two weeks
The weekend before the Auckland stand-off, five teenagers escaped to the roof of Te Puna Wai ō Tuhinapo, the youth justice residence near Christchurch.
Fast food was also used in the negotiations to lure down the teens down. One staff member was injured in the incident.
A "serious event notification" said that seven young people attempted to escape the facility on 24 June. The report was heavily redacted, but it said five youths climbed on to the roof.
At 12.30pm that day, a log of events showed: "Young people call 111 and demand McDonald's or they will push someone off the roof".
In the log's unredacted sections it was not clear what happened with those demands, but during the afternoon the five youths moved to a different part of the roof.
At 6.20pm one came down and was given a hot meal, while "young people on the roof huddle in place".
The remaining four came down at 11am the next day. They were "given kai, offered a shower and [were] medically cleared by Pegasus health".
Chapman told RNZ: "We have undertaken work to harden areas of the residence.
"As with Korowai Manaaki, we have improved our staffing levels to reflect the dynamic operational environment staff work in."