A highly critical investigation has found many baby uplifts by Oranga Tamariki were carried out "without expert advice or independent scrutiny", with little involvement of parents and family prior and no support given to deal with trauma and grief.
There was also a "significant breach" of the Disabilities Convention, Chief Ombudsman Peter Boshier said after releasing the investigation into the removals.
Five inquiries were launched last year after Newsroom released footage of a Hawke’s Bay incident on May 6, 2019, where Oranga Tamariki social workers repeatedly tried to uplift a baby from hospital to the objection of the mother, her family and the midwife involved.
Oranga Tamariki had removed newborn babies from their parents "more by routine than exception" under a without court order, Mr Boshier said.
The investigation looked at 74 cases of babies aged up to 30 days old over a two-year period ending June 30, 2019.
"Removing newborn pēpi from their parents is one of the strongest uses of state power," Mr Boshier said. "New Zealanders must have confidence in how the law is being applied."
Oranga Tamariki is able to use powers for interim custody reserved for urgent cases where there is no other options.
"They should be made without notice in only the most exceptional cases," he said. However, the investigation found in most cases the decisions were made late - "without expert advice or independent scrutiny, and without whānau involvement".
"In most cases the ministry knew about the mother’s pregnancy for months before the birth. There was time for the ministry to engage with parents, whānau and other parties to determine the best place for pēpi."
Contributing factors to the issues included high caseloads and a limitation of Māori specialist staff.
"This appeared to result in cases involving unborn pēpi not being prioritised until the birth was imminent," Mr Boshier said.
He said he believes the level of urgency "was often created by the ministry’s inaction and lack of capacity to follow processes in a timely and effective way".
More than 20 per cent of cases he reviewed involved parents with a intellectual disability, but the parents did not get assistance or advocacy.
"I was very concerned to find that the rights of disabled parents were not visible in either policy or practise. This is a significant breach of the (Disabilities) Convention."
He also found there was little evidence of involvement with parents and family in the planning of the removal process and there was no support offered "to deal with the trauma and grief of their being pēpi removed, while mothers who wished to breastfeed got only limited support".
"I found that parents and whānau were not provided with opportunity for ngākau maharatanga me te ngākau aroha; a period of ‘quality time’ that reflects consideration, empathy, sympathy and love," Mr Boshier said.
Oranga Tamariki released its own report last year on the Hawke's Bay incident, detailing a litany of mistakes made in how social workers dealt with the family.
Oranga Tamariki chief executive Grainne Moss said it brought in changes in November following its own report.
"We have been open, and will continue to be open, about the lessons learnt. We have made changes in social work practice and will continue to do so," Ms Moss said.
"We have made good progress and this report reinforces that our work needs to continue to be done collectively with our partners and other agencies.
"Since our own changes in November last year I can confidently say we are working earlier with whānau and seeing fewer children coming into care. For those who do need to enter care it is more likely to be in a planned way and less likely to be under a section 78."
She agreed the issues around parents with disabilities was an area that a significant amount of work was needed.
Children's Minister Tracey Martin today said the Government would reveal part of the Oranga Tamariki Act.
"Interpretation of the current law has meant that some children may have been unnecessarily traumatised and kept apart from their parents."