CYFS admits gaps in centre practices

Child, Youth and Family has admitted there were gaps and "a lack of clarity" in its procedures when a 16-year-old girl died in one of its youth justice facilities.

But the department said it had made many improvements since the death of Carla Louise Frew in her room at Christchurch's Kingslea Residential Centre last year.

Police found no suspicious circumstances in the death, which is being examined at a coroner's inquest.

Carla should have been checked at least every 90 minutes by staff at the centre, but was not seen for more than six hours before her body was found in her room at 7.55am on January 3 last year.

As a result of a CYFS internal investigation, the acting night supervisor at the centre on the morning of Carla's death, Nick Bentley, was to lose his job, and three other staff were given open-ended final warnings.

The greater punishment for Mr Bentley was because he recorded in the centre's logbooks that the checks had been done when they had not.

Mr Bentley took a personal grievance case and was able to resign from his job with CYFS.

At the coroner's inquest yesterday, CYFS youth justice residences operations manager Chris Polaschek said investigations had revealed a lack of clarity in some procedures for staff to follow.

There were also gaps in procedures that needed to be rectified.

Guidelines had been created to help staff deal with the young people and a national incident reporting system had been set up to monitor staff performance.

Staff at CYFS youth justice centres were now required to visually check on residents at least every hour rather than 90 minutes.

Kingslea night attendant Desmond Dawson said the night before Carla's death was chaotic. Carla and other residents were playing up, there was friction between staff members and Mr Bentley was unwell.

"The place was close to being ready to blow."

Resident night supervisor Delon Lafituanai, who was not working on the shift during which Carla died, said Carla had spent a "considerable time" in the centre's secure unit when she began her stint at Kingslea in October 2004.

"We always kept an eye on her because part of the reason for her being at Kingslea was for her own safety."

Mr Lafituanai said he was disgusted his staff had not done the required checks the morning Carla died.

"I feel really let down and kicked in the guts. Even if nothing happens for 10 years ... our integrity is gone."

Carla's death was only the second to occur in CYFS residences in the past 20 years, but Mr Polaschek warned the risk of another such death was significant "given the changing nature of clients received".