176. A number of factors have caused or contributed to abuse and neglect at the Kimberley Centre and allowed it to persist over many decades. The Inquiry has divided them into four categories: personal factors, institutional factors, structural and systemic factors, and societal attitudes. All of these factors are interrelated.

People at the centre of abuse and neglect

177. Due to and unmet needs, families of disabled children, young people and adults were advised to place their loved ones into the Kimberley Centre where they were at risk of abuse and neglect in care. The circumstances of being placed into care at the Kimberley Centre and include placement by family on the advice of the medical profession, placement by family for respite care due to a lack of community support, and transfers from other State institutions.

178. Survivors were more susceptible to abuse and neglect at the Kimberley Centre due to a lack of agency, a lack of rights, assumptions that they lacked capacity and could not express their will and preference, being either Māori or Pacific person and racially targeted, cultural alienation and loss of identity, and a lack of respect for their personhood.[229]

179. Most survivors had or experienced many of the factors that heightened their risk of abuse and neglect when they were in care.

Factors related to abusers

180. Abusers of children, young people and adults in care at the Kimberley Centre came in all shapes and sizes. Staff abused and neglected children, young people and adults. Abuse and neglect were experienced either one on one, or through more than one person abusing or neglecting an individual.

181. Abusers exploited the vast power imbalance they had over child, young people, and adults in care. For example, some were at greater risk of abuse and neglect because they were non-speaking and were not supported to be able to easily report their abuser or had a physical disability that meant they could not physically escape an abuser.

182. Abusers included nurses, teachers and other staff. It appears that most abusers were opportunistic, but some abuse involved a degree of planning or pre-meditation.

183. Inadequate staff supervision and lack of staff resources likely contributed to the prevalence of peer on peer abuse. Most abusers were in positions of power and had control over the children, young people, and adults in care.

184. Many abusers were adept at hiding their abuse or avoiding accountability once concerns had been raised. Abusers would often lie. Many would also often call the child, young person or adult a liar or trouble maker or would take steps to ensure that they weren’t believed.

Factors related to bystanders

185. Some survivors told the Inquiry that they had been abused or neglected by an individual or group of people in the presence of one or more staff member or volunteer (bystander). Bystanders may not have reported abuse for fear of retaliation or because they believed nothing would be done about it anyway. Social worker Allison Campbell, who helped transition people out of the Kimberley Centre into the community, told the Inquiry about trainee nurses at the Kimberley Centre who saw staff putting soap powder into residents’ porridge. They were disgusted but too junior and frightened to do anything about it.[230]

Institutional factors that caused or contributed to abuse and neglect

Institutional factors relating to the policies, rules, standards, and practices that applied

Standards of Care

186. From 1950 to late 1992 it was left to institutions such as Kimberley, to decide whether and how they would protect the right of people in their care. It is not clear whether Kimberley developed its own standards. From 1993 the Ministry of Health set care standards through their health service contracts.

The Kimberley Centre was overly regimented

187. The Kimberley Centre was a place where institutional routines prevailed over individual needs. The internal audit in 2000 found that there was no demonstrable evidence that individual needs were addressed outside of prescribed routines. The audit found that a culture of institutional care prevailed, and this needed to change to an individualised environment.[231] Staff worked to get their duties done, and no time was made to engage children, young people and adults in activities.

188. Observational research found that staff at the institution determined the course of each day. Children, young people and adults had little or no choice over any aspects of their daily lives and how they were treated by staff. They were almost totally voiceless in decisions about their care. Researcher Paul Milner described the rigid routines of the Kimberley Centre.

“An institution beats to the drum of its own, historical rhythm. There was an appointed time for everything. You only had a certain amount of time to get people through all the showers and then it was on to sitting in the day room waiting for the tea trolley to get wheeled in at its appointed time. If you were quick you got two cups. If you weren’t, you missed out and had to wait for the lunch break. The whole villa would go for lunch, and you had a certain amount of time to eat lunch before the next villa was marched in.”[232]

Data and record keeping was inadequate

189. The Kimberley Centre did not keep records of important data such as ethnicity and complaints. Some documents relating to the Kimberley Centre during the Inquiry period were either unable to be located or unable to be produced by MidCentral District Health Board – such as policies, procedures, guidelines and staff personnel records before 1999.

Institutional factors relating to the vetting, training, development and supervision of care providers

Insufficient staff resourcing and untrained staff

190. Former Kimberley Centre nurse aide Mr NW said there were not enough staff to deal with violent patients and it became difficult to care for such patients.[233] Some staff at the Kimberley Centre were able to work there with no relevant training or qualifications. For example, nurse aides did not require any qualifications. Under staffing contributed to abuse and neglect in care through staff being overworked, tired and under pressure which affected their ability to provide care.

191. David Newman, whose brother New Zealand European survivor Murray Newman was at the Kimberley Centre, discussed the issue of untrained staff: “It was a known fact in Levin that if you couldn’t get a job, you went out to Kimberley. Some people would have worked at Kimberley because it was a job. They had no professional training, and a lack of understanding with regard to the intellectually disabled.”[234]

192. Gay Rowe told the Inquiry about visiting her brother New Zealand European Paul Beale and the lack of staff resources for those in care on a locked ward with some still restrained by their wrists and legs: “There were about a dozen young men in there with special needs and only two assistants to look after them.”[235] New Zealand European survivor Mr EI said there were never enough staff to look after the children at the Kimberley Centre and staff were not experienced. He said there were around two staff members to 30 children.[236]

193. It is unclear what staff vetting procedures were in place at the Kimberley Centre, if any.

Inadequate staff knowledge and training in relevant cultural practices

194. Although it appears that many at the Kimberley Centre were Māori, staff providing care were predominantly non-Māori.[237] Māori culture was not incorporated or fostered in their care. There was limited knowledge, understanding and acceptance of tikanga Māori and te reo Māori. This contributed to a lack of culturally informed practices in the provision of care at the Kimberley Centre.

Culture of institutional care

195. The culture of institutional care at the Kimberley Centre including the physical layout, the isolation of individuals from society and families, and group rather than individual care meant that abuse and neglect were inevitable.

196. Clinical psychologist Dr Olive Webb was involved in the deinstitutionalisation of psychopaedic and psychiatric facilities in Aotearoa New Zealand. She provided expert evidence to the Inquiry about the culture of institutions.”[238] Dr Webb explained: “The culture is built on certain values and concepts which become self-reinforcing. That is why you will see nursing staff who are amazing people, yet still refer to patients as ‘them,’ they still see their patients as people who are somehow enduringly different from, and inferior to, other people.”[239]

197. That culture contributed to the continuation of abuse and neglect at the Kimberley Centre.[240]

Institutional racism and discrimination

198. Equality and freedom from discrimination, including racism, are domestically and internationally recognised human rights.[241] Each person has an equal right to have their human rights respected, protected and fulfilled.

199. Part 7 of the Inquiry's final report, Whanaketia – Through pain and trauma, from darkness to light, talks about how broader societal values and attitudes towards socially marginalised populations are often reflected in the culture of an institution. Racist and negative attitudes towards Māori and Pacific children, young people and adults were common and contributed to abuse in institutional care, including at the Kimberley Centre.

200. At the Inquiry’s State Institutional Response Hearing, Director-General of Health Dr Diana Sarfati said:

“I acknowledge that institutional racism in legislation, policy and systems has contributed to the abuse of Māori and Pacific people in health and disability care settings.”[242]

Dr Sarfati further acknowledged: “Māori are more likely to experience compulsory assessment and treatment than non-Māori and also more likely to be secluded.”[243]

Lack of diversity in staff and management

201. Former staff member Mr NW (Ngāti Maniapoto) described how many at the Kimberley Centre were described as not having families, or their family wouldn’t come to visit. He stated:

“Further, there weren’t that many Māori staff at Kimberley, despite there being quite a few Māori patients.”[244]

202. Survivor Lusi Faiva explained that no one talked about her Samoan heritage at the Kimberley Centre. There was no recognition or interest in inclusion of her Samoan culture there. It is likely that a lack of diversity among Kimberley Centre staff and management contributed to an absence or lack of respect led to an increased risk of abuse or neglect. Some staff abused or neglected those in care who were different from them, were aligned with social attitudes relating to racism and ableism.[245]

Lack of appropriate complaints investigation processes

203. The Kimberley Centre’s management failed to properly investigate serious incidents.

204. New Zealand European survivor Murray Newman went through a plate glass window at the Kimberley Centre. His mother was informed of the incident by a staff member ‘off the record’.[246] She was later invited to attend a meeting at the Kimberley Centre with a room full of staff she didn’t know and who didn’t introduce themselves. She asked the room whether someone could tell her what had happened to Murray and was surprised to hear a male nurse respond saying that they were hoping she would tell them.[247] After a period of silence, a staff member said if she couldn’t tell them what happened there was no point in continuing.

205. Murray’s mother demanded an investigation into the incident. It was not clear what the complaints process was and so she met with the medical superintendent. He asked her what she expected him to do about it. She responded that it was not for her to tell him what to do. He responded by threatening to discharge Murray from the Kimberley Centre.[248]

206. David Newman, Murray’s brother, regards the medical superintendent’s approach as a deliberate cover up by the Kimberley Centre management with standover tactics to belittle and humiliate his mother, and silence her from taking the matter any further.[249]

207. As described in Chapter 5, in 1999 the coroner criticised the Kimberley Centre management’s internal inquiry into a choking death. The coroner found that the failure of the inquiry to ascertain how the individual obtained the food which he choked on was a very definite cover-up attempt.

Institutional factors relating to processes available to make complaints about abuse and neglect

Lack of complaints processes

208. Institutions should have complaints processes, including a policy that sets out the channels and methods the organisation will use to receive complaints and a detailed explanation of the complaints handling process.

209. The State has been unable to provide the Inquiry with information about any complaints processes for the Kimberley Centre. The Inquiry has been unable to locate any records of complaints relating to abuse and neglect during the Inquiry period prior to 1994. The complaint records that are available for the period 1994 to 1999 are limited to a basic register of complaints with no further details about the complaints.

210. Abuse and neglect were likely able to continue as many survivors were unable to report it because there were no clear complaints systems in place. Some survivors did not have the ability to make a complaint without assistance, for example if they were non-speaking. Others feared that reporting may lead to retaliation or otherwise negatively affect their lives or saw that nothing changed when someone did report abuse, as described in Chapter 4.

211. Social and cultural isolation in the Kimberley Centre contributed to abuse and neglect. Many children, young people and adults had limited or no visits from family or whānau as this was discouraged. They therefore lacked the close support of people who could advocate for them and help protect them from abuse and neglect.

Failure to hold people to account for abuse and neglect

212. In the absence of any legal direction it was unclear how senior leaders and management in Kimberley should handle compliance. A culture of failing to hold people accountable for abuse and neglect in care contributed to further abuse and neglect at the Kimberley Centre. If people know that there are likely to be no serious consequences for abuse and neglect, they can act with impunity.

213. David Newman spoke of the lack of accountability for what happened to his brother. “[Murray] was of a slight build but was able to go through the plate glass with his arms up. It’s extraordinary that someone of [his] build was able to break through plate glass. The thought was that he was been chased by either staff or another patient and was determined to get away. What is equally as extraordinary was the fact that no one apparently knew how or why this incident occurred with no accountability yet again.”[250]

214. Expert witness and Director of the Donald Beasley Institute Dr Mirfin-Veitch told the Inquiry that when staff knew about abuse, often nothing was done to stop or address it:

“At another very obvious level, a repeated refrain in the stories (and confirmed in some of the presented third party evidence) was that those in power knew the individual had been abused but nothing was done to stop or to address it on an ongoing basis. Furthermore, these same individuals almost without exception noted that they knew their peers were being assaulted but that they felt they were unable to call it to the attention to anyone with the power to stop it. Some went as far as to say they knew nothing would be done anyway.”[251]

Failure to report complaints to NZ Police

215. Under the Crimes Act 1961, which largely continued provisions under the Crimes Act 1908, it was a crime to:

• rape or have unconsented, unlawful sexual connection with another person[252] or to have sex with a child under the age of 16[253]
• ill-treat or neglect a child or vulnerable adult[254]
• wound, injure or assault anyone.[255]

216. The Inquiry has received evidence recording different forms of abuse at the Kimberley Centre including sexual abuse by peers, and physical assaults by staff. The Inquiry has received no evidence that consideration was given to NZ Police referrals in any of these examples despite the serious nature of the alleged conduct. This suggests there was a reluctance to share knowledge of abuse outside of the institution. Examples of the documented abuse are summarised below.

217. Dr Tony Attwood, a renowned clinical psychologist, explained that prior to him leaving the Kimberley Centre in 1984, he “went to the chief medical officer with hundreds of drawings revealing instances of abuse,” but he could see the chief medical officer “didn’t want to know”. Dr Attwood considered it a tragedy that survivors had to live in such circumstances, let alone those that were preventable.[256]

218. In 1993 a district inspector highlighted “a rash of reports of assaults by staff upon residents” in a memorandum to the Director of Mental Health at the Department of Health:

“There is a continued tension between internal inquiries on the one hand and the possibility of police inquiries on the other … [the Kimberley Centre’s] primary duty is not to be a good employer but to be a good carer and that the residents at Kimberley Centre have equally as much right to have persons who assault them prosecuted or at least investigated for the purpose of prosecution, as do people who are living in the wider community.”[257]

219. In July 1993, a staff member was accused of serious misconduct for physically restraining a person by sitting on him and placing him in a headlock, physically assaulting another person by kicking him, and yelling in a threatening manner at others in care.[258] The service manager said: “It is not acceptable to kick residents, to restrict their mobility, to deprive them of their property, such actions are considered to be abuse.” The staff member was advised that serious conduct generally leads to dismissal however they received only a formal written warning and a plan for further training. This was despite the manager acknowledging in an earlier letter: “I cannot guarantee the safety from abuse of residents if [the staff member] remains in the position he occupies. There is no position elsewhere within KC [Kimberley Centre] that he can be redeployed into.”[259]

220. In December 2000, a staff member allegedly kicked a female in the shoulder / neck region of her back while she was lying on the ground in the day room. The force used was described as kicking a ball hard.[260] An employment investigation was initiated following an anonymous complaint. The staff member was suspended and later dismissed from employment.[261] The MidCentral Health Incident-Accident-Hazard Report form did not contain any option for an NZ Police referral.

221. In October 2002, a letter was sent by a Kimberley Centre staff member to a manager at the local health board reporting that a colleague had physically abused an individual by punching him in the mouth, as well as other suspected instances of abuse. The complaint was made anonymously for fear of reprisal. The staff member said there was no one at the Kimberley Centre they could trust to confide in.[262] This complaint demonstrates both the institutional culture and lack of an accessible complaint mechanism. Research conducted at the time of the Kimberley Centre deinstitutionalisation by Sue Gates and others identified that some staff reported a culture of staff covering up abuse, such as covering for their friends[263] or informing senior staff off the record but not wanting to take the matter any further.[264]

222. The Inquiry concludes that overt abuse at the Kimberley Centre was not referred to NZ Police, and therefore not investigated or prosecuted by NZ Police. The Inquiry considers children, young people and adults that suffered abuse and neglect were likely to have been denied access justice. It appears that contributed to a culture where people were overlooked or ignored. Further, as outlined earlier in this case study, an insidious and pervasive form of abuse that occurred at the Kimberley Centre was the neglect of people’s lives. Neglect is much harder to uncover, investigate and prosecute. It does not often feature in NZ Police prosecutions. Yet the impact of chronic neglect can cause more harm than overt abuse.[265]

Institutional factors relating to oversight and monitoring

223. A lack of safeguarding of children, young people and adults in care contributed to the three choking deaths at the Kimberley Centre within a two-year period. In relation to one of the cases, the coroner expressed concern about the amount of unsupervised time there was for residents.

224. Chapter 4 sets out examples of serious peer-on-peer physical and sexual abuse. The extent of peer-on-peer abuse indicates inadequate supervision of children, young people and adults, and insufficient staff resources may well have contributed to this.

Systemic factors that caused or contributed to abuse and neglect

Societal attitudes relating to ableism and disablism

225. The oppression of disabled people (disablism) led to their segregation and isolation in the Kimberley Centre where they were part of an institution that enabled abuse to occur.

226. Prejudice and ableist views that put people in the Kimberley Centre in the first place continued inside the institution. Survivors told the Inquiry about the dehumanising environment and practices at the Kimberley Centre. They were stripped of their individual identity because they were dressed the same, given the same haircuts, and grouped and categorised based on their disability.

227. Expert witness and psychologist Dr Olive Webb found that the prevailing staff and system attitude in institutions is that “people with disabilities are viewed as being incompetent, uneducable or naughty because of their disability. The belief is that someone with a learning disability is unchangeable”.[266] These are ableist views that normalised abuse and neglect.

State policy of institutional care

228. The State policy emphasis on large-scale institutionalism for psychopaedic and psychiatric care contributed to abuse at the Kimberley Centre and other psychopaedic institutions in Aotearoa New Zealand. The policy caused the separation, segregation and congregation of people with disabilities into psychopaedic institutions. The policy was contrary to the positions of the Intellectually Handicapped Children’s Parents’ (IHCPA), the World Health Organisation (WHO), and a report by Dr Burns for the British Medical Association, which all supported community facilities for children and adults with disabilities.[267]

229. Expert witness and disability researcher Dr Hilary Stace said the normalisation of institutionalisation of disabled children was hard for individuals to fight.[268] Research by Dr Mirfin-Veitch and Dr Conder into institutional care found: “The story of Kimberley is, in many ways, the story of an institution resistant [sic] to change. Many of the social practices and systems of care described in the research appeared rooted in the same negative social construction of people with a learning disability that had led to the construction and populating of New Zealand’s major institutions with some of its most vulnerable citizens.”[269]

Societal attitudes that caused or contributed to abuse and neglect

Prejudicial attitudes towards disabled people

230. During the Inquiry period, disabled people were generally not seen as human, and they were treated in care as if they had no inherent human value. This underlying prejudice underpins the nature and extent of abuse in care set out in Chapter 4. The prejudice stems from the belief in eugenics at the time, which perceived disabled people as inferior beings that should be segregated from society to prevent the reproduction of a subnormal race. This thinking led to disablism – the oppression of disabled people.

231. Segregating and congregating disabled people in care institutions where they continued to be stigmatised demonstrated that disabled people were not valued equally with non-disabled people. Disabled people in care were denied inclusion and participation, their educational opportunities were limited and neglected, and they were generally unable to develop their independence. Being kept away from their family, whānau and community exacerbated this.

232. Congregating people based on perceived disability led to assumptions of similarity between individuals, and people were not treated and cared for as individuals. This led to staff carrying out dehumanising and disempowering routines for all increasing the likelihood of abuse and neglect.

Lack of understanding of te Tiriti o Waitangi

233. Societal attitudes that were ignorant of te Tiriti o Waitangi were reflected in the Kimberley Centre. It was not well known in Pākehā society at the time that te Tiriti o Waitangi provided for the active protection of te reo and tikanga. This lack of knowledge was reflected inside the Kimberley Centre. In society and in the Kimberley Centre, Māori cultural identities, heritage and language were suppressed and discouraged. Tino rangatiratanga as guaranteed to Māori by te Tiriti o Waitangi necessarily includes the authority to care for and protect their own.[270] Part 2 of the Inquiry's final report, Whanaketia – Through pain and trauma, from darkness to light, discusses the Crown’s intrusion into the sphere of tino rangatiratanga, and how Western notions of disability and mental health led to the mass institutionalisation of whānau hauā Māori, tāngata whaikaha Māori and tāngata whaiora Māori. The Kimberley Centre was the largest psychopaedic hospital in Aotearoa New Zealand that provided care for whānau hauā me tāngata whaikaha Māori.

234. The Waitangi Tribunal has found that the principle of active protection includes the Crown’s responsibility to actively protect Māori health and wellbeing through the provision of health services.[271] The Waitangi Tribunal has further concluded that part of the Crown’s active protection obligation is to ensure that health services are culturally appropriate. An approach to health care that assumes that the needs of all patients are largely the same not only undermines the recognition of tikanga Māori but may also result in a failure to recognise and provide for the specific health needs of Māori.[272]

235. Dr Tristam Ingham, a member of the Inquiry’s Kaupapa Māori Panel at the Ūhia te Māramatanga Disability, Deaf and Mental Health Care Hearing, told the Inquiry that the Crown’s approach to tāngata whaikaha Māori has been a pervasive, long-standing, highly systematised and highly controlled approach over many decades and generations. He explained that the approach has specifically included segregation and removal of tāngata whaikaha Māori from their whānau, assimilation of Māori through suppression of cultural practices and attempts to systematically eliminate people whom the Crown considered ‘undesirable’ on the basis of policies underpinned by eugenic ideologies.[273]

236. At the Kimberley Centre, whānau hauā me tāngata whaikaha Māori experienced institutional racism, targeted abuse and cultural neglect.[274] During their time in care, they were isolated from the protection of their whānau, hapū and iwi, rendering them particularly susceptible to abuse and neglect.[275]