The disappearance of the Phillips children was extraordinary.
The failures identified in the official inquiry into their disappearance are disturbingly familiar.
Poor information sharing. Agencies working in silos. Warning signs not being brought together. Whānau concerns being minimised. Risk to children being underestimated. Opportunities for earlier intervention being missed.
The Public Inquiry into the Disappearance of the Phillips Children, led by former High Court Justice Simon Moore KC, has concluded that more could have been done both to prevent the children disappearing for a second time and to recover them earlier.
At the centre of its findings is one fundamental failure: the agencies responsible for protecting the children never consistently brought all of the information, expertise and powers available to them together.
The Government has accepted all of the Inquiry’s recommendations and apologised to the children.
But the report raises a much bigger question for Aotearoa.
After decades of inquiries, reviews and promises to improve child protection, why are we still being told that agencies need to communicate better with each other?
Nearly four years missing
Tom Phillips first disappeared with his three children in September 2021.
They were missing for 18 days before returning.
Around December 10, 2021, Phillips disappeared with them again.
This time they would remain hidden around Marokopa for almost four years.
The search finally ended on September 8, 2025, after Phillips encountered Police following an armed robbery.
A Police officer was seriously wounded after being shot by Phillips, who was then fatally shot by another officer.
All three children were recovered that day.
The Inquiry was subsequently established to determine whether government agencies had taken all practicable steps to protect the children and whether more could have been done to locate them sooner.
Its answer is clear.
More could have been done.
The harm to the children was underestimated
One of the most significant findings goes to the way the situation itself was understood.
The Inquiry found that for significant periods, the harm caused by isolating the children from their family, friends and society was underplayed, minimised or overlooked.
The concerns of their maternal whānau were also frequently treated as part of a parenting dispute rather than being understood through the lens of child safety and wellbeing.
That distinction matters enormously.
If authorities see a case primarily as a disagreement between adults, the response can look very different from one where children are understood to be facing escalating harm.
As the years passed, those children were separated from their mother, siblings, wider whānau, education, healthcare and ordinary community life.
The Inquiry found that this ongoing harm should have been recognised much earlier and with considerably greater urgency.
Police and Oranga Tamariki weren’t talking enough
Perhaps the most consequential failure identified was between Police and Oranga Tamariki.
Police did make a report of concern to Oranga Tamariki following the first disappearance, something the Inquiry specifically regarded positively.
But crucial information was not consistently shared afterwards.
The Inquiry found Police should have ensured Oranga Tamariki had all relevant information and that critical discussions between the two agencies continued.
Better communication could have meant the Police safety plan was understood across agencies, mental-health concerns were properly discussed and appropriate referrals made.
It may also have strengthened the agencies’ involvement with the Family Court.
The Inquiry concluded that clear and ongoing communication between Police and Oranga Tamariki may have prevented, or at least made considerably more difficult, the second disappearance.
That is one of the most sobering findings in the entire report.
No common understanding of the danger
Years later, the same problem remained.
A senior Oranga Tamariki official told the Inquiry there had never been a common accepted understanding between Police and Oranga Tamariki about the level of concern for the children.
The Inquiry found information needed to move in both directions.
Oranga Tamariki, as the specialist child-protection agency, should have more clearly communicated the significant grounds it had for concern about the children’s safety and wellbeing.
Police, meanwhile, held information that could have helped Oranga Tamariki better understand the circumstances.
Instead, the information flow was deficient.
And the Inquiry concluded that deficiency was detrimental to the wellbeing of the children.
Opportunities were missed during the search
Problems continued after the children disappeared.
The Inquiry found Police should have increased Criminal Investigation Branch staffing and reviewed the direction of the investigation considerably earlier.
The initial assessment that there were no significant concerns about the children contributed to the investigation increasing in intensity only gradually.
Even later in the search, resources remained an issue.
In late 2024 and 2025, Police did not always have enough staff to monitor covert camera feeds in real time.
That had a direct consequence.
When the group appeared on camera on April 5, 2025, Police did not see the footage until five days later.
The Inquiry found additional staff should have been allocated to monitor and review camera feeds when surveillance had become a central part of the investigation strategy.
The missing multi-agency team
One of the strongest recommendations emerging from the report is remarkably straightforward.
Get everyone around the same table.
The Inquiry concluded the unusual complexity of the case called for a dedicated multi-agency approach involving Police, Oranga Tamariki, the New Zealand Defence Force and relevant specialist Police units.
Health and education agencies could also have contributed when required.
Instead of individual agencies periodically supplying assistance to a Police-led investigation, a permanent working group could have combined intelligence, specialist expertise, child-protection knowledge and operational capabilities.
The Inquiry noted this type of interagency structure is hardly revolutionary.
Police already work collaboratively with agencies such as Customs in complex organised-crime investigations.
The Phillips case, the Inquiry concluded, should have prompted a similar response.
Police did many things well
The report is not a blanket condemnation of the agencies or people involved.
That distinction is important.
The Inquiry acknowledged the care, diligence and commitment demonstrated by Police, Oranga Tamariki and the Defence Force.
It found Police eventually deployed sophisticated and innovative methods to narrow the search area, drawing on specialist groups, NZDF capabilities and private-sector technology.
It also found the final operational response leading to deployment around Marokopa was excellent given the circumstances.
Oranga Tamariki was commended for careful planning ahead of the eventual recovery of the children, particularly during the later stages of the operation.
The issue was therefore not that nobody cared.
It was that a system containing many committed people still failed to consistently connect the information, responsibilities and expertise sitting inside different agencies.
That is arguably the more uncomfortable finding.
Police and Oranga Tamariki accept the findings
Police Commissioner Richard Chambers has accepted the Inquiry’s recommendations.
Police acknowledge there were gaps in information sharing and follow-up discussions and say they will work with Oranga Tamariki to implement changes, particularly around interagency cooperation.
Oranga Tamariki has also accepted the recommendations.
Chief Executive Amanda Malu says the agency will work through the findings and actions required following the Inquiry.
The Government has accepted every recommendation.
Minister Louise Upston has also issued an apology to the Phillips children, acknowledging that government agencies did not take every practical step available to protect them.
But haven’t we heard this before?
That is where the Phillips report reaches beyond one extraordinary case.
New Zealand’s child-protection system has been examined repeatedly.
Over decades, inquiries into tragedies involving children have repeatedly confronted questions about whether agencies shared information, understood risk, listened to whānau and worked together.
That does not mean every case is the same.
Nor does it mean the Phillips disappearance could easily have been prevented.
The Inquiry itself repeatedly stresses how exceptional the circumstances were.
But many of the organisational weaknesses it identifies are not exceptional at all.
Information sitting in one agency but not another.
Different organisations holding different pieces of the same puzzle.
Concerns being viewed individually rather than collectively.
No shared assessment of risk.
No single multi-agency plan.
No consistent mechanism ensuring somebody follows up.
Those are systemic questions.
For Māori, there is another lesson
For Māori whānau, the findings also touch on something deeper about the relationship between families and the state.
When whānau raise concerns about tamariki, are they being heard?
Or are their concerns being categorised as conflict between adults?
The Phillips Inquiry specifically found the maternal whānau’s concerns were at times minimised as part of a parenting dispute.
That finding should matter well beyond this case.
Whānau frequently hold information no government database can replicate.
They know changes in behaviour.
They understand relationships.
They recognise when something is wrong.
In a genuinely child-centred system, information from whānau should become part of the overall risk picture rather than simply another competing account to be filed away.
For Māori, the principle of whakapapa makes that particularly significant.
Protecting tamariki cannot be separated from understanding the network of whānau relationships surrounding them.
A child doesn’t live inside an agency boundary
Perhaps that is the simplest lesson from the entire report.
Children don’t experience government in departments.
A child doesn’t know whether a piece of information belongs to Police, Oranga Tamariki, Health, Education or the Family Court.
They simply experience whether the adults and institutions responsible for protecting them are working together.
The Phillips Inquiry found that too often they were not.
Its conclusion on interagency coordination is unequivocal: better communication and coordination could have better protected the children’s welfare, identified risks earlier and potentially resulted in their recovery sooner.
The test now is whether anything changes
The recommendations have been accepted.
There will be new procedures.
There will be discussions about information sharing.
There will be work on multi-agency responses.
And there will undoubtedly be assurances that lessons have been learned.
But that cannot be where this story ends.
Because the measure of an inquiry is not how many recommendations a Government accepts on the day the report is released.
The measure is what happens when the next child is at risk.
When the next whānau raises the alarm, does somebody listen?
When Police know something Oranga Tamariki needs to know, does the information move?
When Health, Education or another agency holds another piece of the puzzle, does somebody bring those pieces together?
And when nobody’s ordinary operating procedure quite fits the circumstances, does the system adapt around the child — or does the child disappear between the gaps?
Three children spent almost four years isolated from their mother, siblings, wider whānau and society.
Their circumstances were exceptional.
The lessons should not have to be.
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