This inquiry is examining the nature and extent of abuse in care and the reasons why many of the country’s youngest and most vulnerable people have been abused while in the care of the State and faith-based institutions.

Generations of children, young people and vulnerable adults have been subjected to abuse and neglect in ways and on a scale that most New Zealanders will find incomprehensible.

Māori have suffered more than most, both individually and collectively. They have been overrepresented in care for generations. They have also been disproportionately subject to abuse, as have people with disabilities, including those with mental illness(2). Pacific people have also been badly affected (3). And to be clear, the abuse continues to this day (4).

For many years, victims and survivors, community leaders, academics, human rights campaigners and others lobbied for an investigation into this shameful subject (5). New Zealand owes a great debt to those who worked tirelessly to this end, particularly survivors themselves who were at the forefront of efforts to establish this inquiry.

The inquiry’s then chair, Sir Anand Satyanand, carried out extensive consultation on draft terms of reference and, in response to the views of survivors, experts and members of the public, recommended broadening the inquiry’s scope (6). The final terms of reference now cover more types of abuse and neglect than any other similar inquiry in the world. In this report, we generally use the term abuse to include neglect.

The terms of reference also encompass a very broad range of settings, both direct and indirect State care and faith-based care, including child welfare and youth justice facilities, foster placements, adoption placements, all schools, early-childhood facilities, health camps, health and disability settings (both in-patient and community-based), police and court cells and faith-based institutions (whether part of an organised religion or otherwise) (7).

We are required to address the effects of abuse on particular groups, including Māori, Pacific people and disabled people. Reflecting public feedback during the consultation process, Cabinet confirmed that the inquiry would be underpinned by Te Tiriti o Waitangi/the Treaty of Waitangi and its principles, and would partner with Māori throughout its work (8).

The terms of reference emphasise international as well as New Zealand law, including human rights law. The inquiry has an extremely wide timeframe – from 1950 to 1999 – and is able to look before and after that period (9).

Our work has two strands: one looks back to establish what happened and why, and the other looks forward to current systems for preventing and responding to abuse and what changes need to be made (10).

Despite the comprehensiveness of the terms of reference, they can be condensed to four essential questions:

• How and why have people ended up in care?
• What abuse has taken place, why, and with what effects?
• What changes have already been, and can be made to prevent and respond to abuse?
• How should the State and
• faith-based institutions provide redress and rehabilitation to survivors?

These questions apply equally to faith-based institutions and the State – and in some cases people have been in the care of both, and sometimes in numerous care settings. For Māori, these questions must be seen within the context of tikanga Māori as well as broader historical factors such as colonisation, urbanisation, ongoing racial discrimination and the Crown’s obligations arising from Te Tiriti as well as the United Nations Declaration on the Rights of Indigenous Peoples. Successive generations of whānau, as well as the Māori communities in which they live, have had to endure some of the worst effects of institutional care.

For Pacific people, the broader context includes the large-scale migrations of the mid-20th century, the cultural and social impact on Pacific communities, particularly young people, and the social response to this from New Zealanders.

For disabled people, the broader context includes shifts over time from institutional to family care, the need for care relationships from school age through to adulthood, the domination of decision-making by non- disabled people, stigma, shame, whakamā (externalised  shame or guilt), discouragement of individuals from safely getting their care needs met, a history of unnecessary medical intervention, eugenics, segregation, a view that people with disabilities suffer from a deficit rather than simply being different, compulsion, coercion, and bioethical experimentation in care and treatment, and difficulty in accessing care (11).

Despite the complexity of what we must examine, our objectives are simple: we must find practical and effective ways for the State and faith-based institutions to put right the harm that has happened, and to keep children, young people and vulnerable adults safe in future. We have much work to do to achieve these objectives.

This interim report discusses the work we have done so far and notes the key themes and common issues arising from what we have learned.

Nature of the problem

Abuse in care is a serious and long-standing problem.

The abuse and neglect of children and other vulnerable people in care has been a serious and long standing social problem. It is difficult to get an accurate estimate of the total number of people who may have been affected by abuse  in care, due to large gaps and deficiencies in the data available, such as from underreporting of abuse. However, a report we have commissioned suggests that up to about 250,000 may have been abused in care since the 1950s (12). The report found the data currently available has large gaps, which means these numbers are likely to change as our research and investigations uncover more information about the extent of abuse and neglect in care.

The evidence and other information we have received is unequivocal: many people in care today continue to be abused and neglected (13).

The survivors of this abuse are among society’s most vulnerable people. They include children separated from their families and placed in State care in circumstances outside their control, young people in the care of church leaders, people with physical, sensory or neurological disabilities or mental health issues – all people who, for one reason or another, were reliant on others outside their families to care for them and keep them safe. Instead of being kept safe, people left in worse shape than when they arrived.

We have heard from many people who have suffered abuse. The key theme from their experiences is the breadth and depth of their suffering. The types of abuse have included physical assaults, sexual abuse, unreasonable physical restraint, cruel, inhumane and degrading treatment and   punishment, improper use of medical procedures (in extreme cases involving electric shocks on genitals and legs), unjustified solitary confinement and isolation, improper strip searches and vaginal examinations and verbal abuse and racial slurs. We have also heard about many forms of neglect, including physical, emotional, educational, psychological, medical, spiritual and cultural neglect.

Abuse in care has wide-reaching consequences

We are learning about the different impacts on key groups. Māori in particular have been overrepresented in care for generations and recent data shows they have been disproportionately subject to abuse (14) The problem persists to this day despite the chorus of Māori and others who have called for profound change to improve Māori outcomes (15). Oranga Tamariki’s most recent annual report shows Māori today make up 69 per cent of children in care and 81 per cent of the children abused in care   (16).

Disabled people, including people with a mental illness, are another important and often overlooked group. They are more likely to be in care and for longer periods than non-disabled people and are also more likely to be abused (17). We have heard that many suffered particularly from educational neglect. Their learning needs were not acknowledged, they were denied the opportunity to learn to read or write, and as a result they were prevented from reaching their full potential.

This form of neglect can have a compounding effect: people who have received inadequate education are less able to assert their rights, protect themselves and complain when abuse occurs. The lack of readily available data on the nature and extent of abuse of disabled people while in care is one example of how this part of our population has been overlooked and how the experiences and consequences of abuse to this group have gone undocumented.

Similarly, there is little readily available information on the number of Pacific people who have gone into care, or on their experiences of that care, including abuse suffered. For long periods, agencies have not collected or kept consistent data on the number of Pacific people in care or have counted Pacific together with Māori. The limited data affects what we understand about Pacific people’s experiences of care. We are working to understand more about the ways in which Pacific people have suffered abuse in care across our history. Today, Pacific youth are overrepresented in youth justice residences and out-of-home care placements, though not to the same extent as Māori (18).

We acknowledge that some people belong to more than one of the groups we discuss in this report. We accept responsibility for ensuring the voices of survivors are heard no matter what group they come from or perspective they have.

Beyond the physical injuries some victims and survivors are left with, there are many other profound and long-lasting consequences. The list is considerable and includes loss of identity, innocence and sense of belonging, mental health difficulties (ranging from insomnia through to depression, suicidal thoughts and suicide), loss of educational and employment opportunities, poverty, homelessness, relationship and interpersonal problems, family breakdowns, loss of spiritual or cultural identity and drug or alcohol addiction.

The impact is often particularly profound for children who have been severely abused or maltreated, especially if at a young age. They can be left with deeply entrenched impairments, such as an inability to regulate behaviour and emotions, diminished intellectual abilities, language and memory difficulties, and poor cognitive processes to control behaviour and achieve goals (19). Their ability to develop attachments can be affected, which has an impact on their relationships, sense of self-worth and empathy (20).

In many cases, there is a direct line from abuse in care to anti-social behaviour, such as gang membership and crime. Many survivors end up in prison (21).

Survivors may suffer further trauma when they seek compensation or redress. Some have described the process as worse than the abuse itself, pointing to disrespectful, drawn- out, and sometimes traumatising interactions and, in at least one case, the State’s rejection of claims despite the conviction of the abuser as a child-sex offender.

The impact of abuse in care is felt far beyond survivors themselves. It also harms their families, their immediate community and society as a whole. The impact reverberates from generation to generation. This is especially pronounced for Māori, who have suffered the loss of cultural identity through disconnection from their whakapapa, whenua and te reo Māori, and the breakdown of  identification with their whānau, hapū and iwi. The removal of a Māori child into care outside of their whānau also has a negative impact on the tino rangatiratanga of the whānau, hapū and iwi to which the child belongs.

In addition to the impacts felt by individuals, the financial and social costs of picking up the pieces are borne by communities, whānau, hapū, iwi and society generally. Impacts such as poverty, substance abuse and crime stretch community services. Unrealised personal potential manifests in loss of economic productivity and other stresses on the community. Several individual survivors have obtained reports from an actuary, who calculated the loss caused by abuse at up to $910,000 for each survivor (22).

A report we commissioned estimated the cost of abuse in care to New Zealand in 2019 at between 0.4 per cent and 0.8 per cent of GDP (23). The same report estimated the cost of abuse in care to New Zealand for the period 1950 to 2019 at up to $217 billion. These costs are not borne equally across society: Māori in particular bear a higher proportion of these costs, given the inequality that has existed over generations, and the high numbers of Māori who have been abused in care.

The consequences for the individual – and therefore for society, too – persist long after the abuse has ended. One survivor, Mike Ledingham, aptly described the continuing anguish: “It’s not water under the bridge… The pain is still there ... The bishop spoke about closure, but how can you have closure when you wake up having had a nightmare”(24). Or as another survivor, Annasophia Calman, put it: “The abuse I suffered while in care has blackened my entire life” (25).

A history of inaction and ineffectiveness

Survivors have argued for years that the State and faith-based institutions are accountable for abuse that took place while in their care and have complained of failures to respond adequately and provide adequate redress. We do not at this stage make findings of responsibility or fault, but there is no doubt the State has obligations to those in its care, including domestic and international human rights obligations, as well as those under Te Tiriti. These obligations are being tested by claims before the courts, the Waitangi Tribunal and the United Nations. The United Nations Committee Against Torture has expressed concern about New Zealand’s failures to investigate abuse in State care and compensate victims (26). Similarly, faith-based institutions are increasingly facing claims of abuse in their care.

Other countries have collectively conducted nearly 50 inquiries of one type or another into abuse in care (27). In comparison, only limited efforts have been made to examine abuse in care in New Zealand.

The Confidential Forum for Former In-Patients of Psychiatric Hospitals (2005-07) gave individuals a means of talking about their experiences (28). The Confidential Listening and Assistance Service (2008-15) had a similar purpose and was well regarded by many who participated in it (29). However, neither had the scope to fully investigate what occurred.

There have been other reviews and reports. These have included the Auckland Committee on Racism and Discrimination into abuse in children’s residences (1978) (30), the Human Rights Commission (1982) (31), various bodies examining mental health services (32), and the Human Rights Commission again in 2011 (33).

In 1985, the Minister of Social Welfare asked a Māori advisory committee to report into Māori experiences of the social welfare system. The resulting report, Puao- Te-Ata-Tu (Daybreak), identified institutional racism in the social welfare system, and called for whānau, hapū and iwi to assume greater autonomy over the care of Māori children (34).

However no independent inquiry has comprehensively examined abuse or redress involving faith-based institutions in New Zealand.

In general, previous reviews and inquiries had narrow scope, lacked sufficient powers and made recommendations that were ignored or not fully implemented. All fell short of an independent public inquiry with statutory powers and broad scope. The result was continued dissatisfaction.

More recently, discontent has continued to build about the lack of a satisfactory examination of abuse in care, resulting in petitions to Parliament, a campaign by the Human Rights Commission, Waitangi Tribunal claims and calls by prominent figures for an independent inquiry. In 2018, the Government responded by establishing this inquiry.

An independent public inquiry with meaningful powers

Royal commissions are reserved for the most serious matters of public importance (35). In establishing this royal commission, the Government said it wanted to send “the strongest possible signal” about the seriousness with which it regarded the issue. As a result, we have a very wide scope and significant powers, including to set our own procedure, demand that individuals and organisations answer questions and give us documents. That means we will be in a position to make meaningful recommendations for change based on independent investigation, research and listening to survivors and their families.

Details about the features of our inquiry are set out in part two of this report, but it is worth stressing two points at the outset: we are an independent public inquiry committed to working transparently and in public wherever possible, and we will be responsive to survivors’ needs (36). 

In practice, working in public means:

• Survivors and others can see and hear what we are doing.
• Survivors’ voices can be heard by a wide audience.
• Individuals and institutions can be publicly held to account for their actions and inactions.
• Interested parties can participate, promoting fairness and hearing a range of views.
• The public can learn about what happened.
• The public can assess for themselves the soundness and independence of our work.
• The work we do can become a matter of public record.

Activities open to the public include formal hearings, some roundtables, wānanga and hui held in accordance with tikanga Māori, fono observing Pacific protocol, and other forms of public engagement. Some of our activities are streamed live and remain available in accessible formats on our website. Operating in public in these ways fosters robust fact-finding and openness.

In particular ou public hearings involve formal questioning, often from a variety of perspectives, with publicly available transcripts and direct accountability to a wide audience. This ensures institutions are held to account. It also bolsters public confidence in the integrity of our investigations.

Representatives of survivors were clear about the pointlessness of another inquiry that merely listened and did not investigate. One group said a “listening only” inquiry would simply traumatize victims all over again (37).

In being responsive to survivors’ needs, we recognise the need  to be guided by survivors as we plan and carry out our work. For this reason, we established specialist advisory groups of Māori and survivors, and we will continue to engage with survivors and interested parties. We also recognise the need to allow survivors to give evidence in a safe way. We have developed our processes to allow this to happen, such as by ensuring survivor witnesses are not cross-examined.

Many survivors emphasised they wanted us to investigate institutions using our full range of legal powers (38). We have begun doing exactly that, drawing on teams of experienced people equipped to carry out detailed investigative work.

Such an approach is all the more necessary given the mistrust that has been built up through inaction, denial and harmful behaviour – real or perceived – by various governments and other institutions and care providers.

In short, this inquiry is a once-in-a- generation opportunity to address the problem of abuse in State and faith-based care. The following sections of this report explain how we are working, the key themes we have seen to date, and our plan for the work ahead.

Next: Part Two - How we are working