Minister for Children Tracey Martin says there have been "serious consequences" as a result of the attempted uplift of a baby in Hawke's Bay, which sparked public scrutiny.
The ministry released its internal review into the attempted removal of a six-day-old baby from his 19-year-old mother, which found a raft of failings by its staff.
The review stated that while safety concerns for the baby warranted the ministry's involvement, staff failed to meet the standards expected of them throughout the ordeal - and has apologised to the family through their lawyer.
Ms Martin told Morning Report more than 150 Section 78 custody order cases out of 309 from the inception of Oranga Tamariki up to 30 June 2019 had been looked into.
She said in that analysis she'd been told there were no similar cases to the Hawke's Bay one, but there had been implications as a result of this case.
"We've made immediate changes to the way that this particular site will manage things going forward, there have been serious consquences for staff at that site, there will be other consequences.
"There have been changes in personnel at that site, but those are employment matters."
She acknowledged that Oranga Tamariki got "very little" right in this case and that practice standards were not adhered to.
"I just want to be clear, this was always an internal review Oranga Tamariki, never a judgement or a review into the family.
"What the review tells us is that yes, they were correct, there were concerns for this baby. But pretty much everything from that moment forward failed to meet the practice standards."
The attempted removal was captured on film by Newsroom who brought the story to public attention, but Ms Martin and Oranga Tamariki's head questioned the video at the time. However, Ms Martin told Morning Report's Corin Dann she did not believe an apology was required and still had not watched it.
"I personally won't ever accept that trial by social media is the way to do care and protection ... I don't need to watch the video."
She said she did not need to watch the video in order to conduct her job.
"It's a 45-minute video and this report is about what happened before what built to what was that video. I take issue with the fact that supposedly we would've done nothing, [that] I would've done nothing, unless a video had came out.
"The suggestion is I would've done nothing. The public response and everything that took place from that - Judge Becroft's reponse, the Ombudsman's response, the commissioning agency's response - absolutely, that is all a side effect of that video.
"You're suggesting I need to watch a 45-minute video, and I would say to you that the outcome we have now is me doing my job - making sure that we change Oranga Tamariki into the child and protection service that we need it to be, so this is part of me doing my job, and I didn't need to watch a 45-minute video to do my job."
Ms Martin said the problems present with Oranga Tamariki were a continuation of the expert advisory panel's finding in 2015 of systemic issues with Child, Youth and Family.
"This is the very reason that I'm appointed to do this job, is to make this change, so it was always going to take time and I think if there is a silver lining out of this terrible event, it is that it's focused our minds that this change needs to take place faster."
She said she hoped that prevention and early intervention in the future would involve the community, iwi and hapu more.
"[That] our children are cared for in communities, we all keep them safe, and the state has a minimal role, and most of that is around providing resources for whāngai families to actually care for these children."
'How many of those babies should not have been taken? ' - midwife
One of the midwives of the mother at the centre of an Oranga Tamariki review told Morning Report she still doesn't have confidence in the ministry, despite the review.
Jean Te Huia, one of the midwives for the mother who was fighting against the removal, described the mother's experience with Oranga Tamariki as horrific.
She said it never acknowledged any of the young mother's efforts to improve her life to prevent her child being taken.
After the incident, Mrs Te Huia said she set up a social media page and many whānau spoke about the "appalling relationship" they had with social workers, and government departments associated with Oranga Tamariki.
The review, which the whānau in the case refused to take part in, found staff had failed to build a good relationship with them.
There was no family group conference with whānau to discuss what's called a Section 78 interim custody order before it was served.
However, Mrs Te Huia said it was a bigger problem than just one social worker failing to work with whānau.
"It's difficult to assume that the blame would rest with a social worker when we have a whole line of command that is supposed to be there to check whether or not the processes, policies and practices of a social worker have been correct in the removal of a newborn baby, but yet again we see how easily a baby is removed.
"There have been 978 newborn babies apprehended and taken from their mothers at birth in this country, under Section 78, which is a 'without notice' [order] in the last three years. The number is appalling."
Although the report vindicated the whānau's criticisms of what happened, it raised more questions about the Māori babies taken by the state, Mrs Te Huia said.
"These are huge issues that we're confronted with, how many of those babies should not have been taken? In this case, it [the review] proves that this section was not used appropriately, and in how many of the other cases would it also have been found that that section could not have been appropriately in their case."
She said there had been enough reviews to show that state care did not work.
"I mean if it's continuing on a daily basis today with so many people upset about it, then it can't be working. It's not working for Māori, it's not working for children, and it's not working for New Zealand.
"We all have to be asking why has it continued to happen despite all the reviews, despite all the money being thrown at it, why has it continued not to work? And I would have to say it's simple, state care doesn't work for children, state care will never work for children.
"I don't agree that we should continue to review an organisation that continually fails and the response from the government is to continue to throw money at it."
The money spent on improving the organisation could be better used on supporting whanau to retain children, she said.
Kaumātua and whānau advocate Des Ratima, who was called into help negotiate with police during the attempted uplift in Hawke's Bay, was glad the ministry had apologised but said there were still some missing pieces.
"If you are apologising, that means you did something wrong, which includes how this whole thing got started. They've accepted that they didn't do the right investigations at the start, which means they put their Section 78 into action without the complete information," Mr Ratima said.
"Why was it that Oranga Tamariki at that stage couldn't see that, that's a real dilemma for me."
He said the ministry may want to change but it could not do that on its own.
"I don't think they can make the changes without assistance from the iwi, without assistance from the community.
"On the iwi perspective and the community perspective, we're happy to help and to engage, and that's what I can say will then give us reassurace that they can do things better."
Minister for Children Tracey Martin told Morning Report she agreed with Mr Ratima, and had already been talking to iwi and hapū about strategic partnerships.
There are no figures to show how interim custody orders are made without notice - meaning the families don't get a say.
As a result of this case, Oranga Tamariki is changing the system to ensure whānau are automatically told, unless a child or baby is in imminent danger.
In those cases, there will be greater scrutiny before the order is signed off and goes to court.
Children's Commissioner Judge Andrew Becroft described the report as a damning indictment at every step of the process. He said that it was unlikely to be an isolated event.
The key changes would be around how those custody orders were applied, he said.
"More careful consideration of when 'without notice' applications are required to be made. I think where Māori children are involved, much greater efforts [are needed] to involve wider family and hapū and iwi, because when it was done in this case there were solutions provided."
Other recommendations in the report call for more staff training and greater supervision for family group conferences.
Oranga Tamariki chief executive Grainne Moss has committed to making sure the same mistakes do not happen again.
She said she would be reviewing 'without notice' cases every month, but there was no plan for a wider investigation into what happened in the past.