245. The Inquiry finds:

Circumstances that led to individuals being taken or placed into care

1. There were different pathways for disabled children, young people and adults to be taken or placed into care at the Kimberley Centre, which had been promoted as an ideal place for disabled people to receive care and training.

2. Many disabled children, young people and adults were placed at the Kimberley Centre by their family, commonly on the advice of a medical practitioner, in the belief that it was the best place for them.

3. Some were sent to the Kimberley Centre by their family for respite care and due to an acute lack of community support and resources for their loved one to remain at home.

4. Some were placed at the Kimberley Centre by the State through transfers or patient swaps with other institutions such as Campbell Park School in Waitaki Valley, Lake Alice Psychiatric Hospital in Manuwatū-Whanganui and Marylands School in Ōtautahi Christchurch.

5. Many whānau hauā me tāngata whaikaha Māori were in care at the Kimberley Centre due to a lack of proper support in the community for whānau, and their marginalisation as a result of the ongoing effect of colonisation and urbanisation. The State failed to engage with and properly support whānau Māori, hapū, iwi and hāpori to care for their own.

Nature and extent of abuse and neglect

6. Physical and sexual abuse of disabled children, young people and adults at the Kimberley Centre was pervasive and severe.

7. Physical abuse by staff and some peers was common and normalised at the Kimberley Centre. This was reflected by the ‘Kimberley cringe’ where survivors would cower and protect their head if they were approached quickly.

8. Staff and other patients at the Kimberley Centre committed rape and severe sexual assaults involving intimidation and punishment on disabled children, young people and adults. Young people were forced to abuse other children and young people.

9. Some staff took payment from groups of external abusers to organise rapes targeting Māori and non-speaking disabled children and young people.

10. Seclusion and restraint was misused. Many disabled children, young people and adults were placed in seclusion, sometimes as punishment for their behaviour. Some were sedated in seclusion until they calmed down, which could take hours or days. Others were locked into day rooms for long periods of time and overnight with the lights off because of understaffing, in breach of policy.

11. Neglect was pervasive. Survivors experienced psychological and emotional neglect, physical, cultural, medical, nutritional and educational neglect.

12. The emotional and psychological needs of disabled babies, children, young people and adults were largely neglected – they were not hugged, cuddled, or loved. There was no opportunity to bond or form important attachments with caring and loving adults.

13. The physical environment at the Kimberley Centre was neglectful with few activities and little to occupy disabled children, young people and adults in care, who spent 80 percent of their time engaged in no form of purposeful activity and 70 percent of their time in their villa.

14. Disabled children, young people and adults were often not treated with basic human dignity and lived within an institutional environment that devalued and dehumanised disabled people.

15. Disabled children, young people and adults’ individuality was stripped away by having to share from pooled clothing, having the same haircuts and being categorised based on their disability.

16. Staff did not engage in meaningful conversations with disabled children, young people and adults. Communication was transactional. Observational research noted that 63 percent of conversations lasted less than one minute.

17. Nutritional practices were poor. Some disabled children, young people and adults reported that they lost weight, were not fed for long periods, and some were fed with feeding tubes that were later assessed as not medically required.

18. Dental care was inadequate, with some disabled children, young people and adults receiving no dental care.

19. Neglectful oversight by staff led to three people dying from choking on food. In one case, a coroner found that the Kimberley Centre management’s inquiry into responsibility for a choking death was a cover-up attempt.

20. Cultural needs were neglected:

a. Māori culture and identity was not supported or nurtured. For whānau hauā this was a transgression against whakapapa.
b. Pacific Peoples cultures and identities were not supported or nurtured.

21. Some disabled children, young people and adults received significant quantities of medication including antipsychotic and sedative medicines with harmful side effects. In one case a hallucinogenic medication was given to two young people without consent.

22. Very few disabled children and young people received training or any form of education at the Kimberley Centre. Some survivors regressed.

Impacts of abuse and neglect

23. The abuse and neglect at the Kimberley Centre harmed survivors’ physical and mental health, their psychological, emotional, cultural and spiritual wellbeing, and their educational and economic prospects.

24. The abuse and neglect experienced denied survivors their personhood, and their human promise or potential. Many people spent the majority of their lives in the institution and died there.

25. The neglect experienced by survivors was chronic and pervasive. The longer the duration of neglect, the more severe its effects were. This is reflected in the significant and lifelong impacts for survivors of neglect at Kimberley. Few survivors later went into paid work or had more than a basic standard of living.

26. For some survivors, excessive medication took away their quality of life and negatively impacted their personality.

27. Māori survivors experienced a lack of access to their culture and identity. This diminished their mana and was also a transgression against their whakapapa.

28. Few survivors received redress, counselling or rehabilitation for their abuse and neglect at the Kimberley Centre. Survivors who were moved out of the Kimberley Centre, and their whānau, had not been equipped to be protected from further abuse and neglect, and to live a good life.

29. Families carried the guilt of sending a family member to the Kimberley Centre when they later found out how their family member was treated there.

30. The harm to survivors and their families has been transferred over generations.

Factors that caused or contributed to abuse and neglect

31. The following personal factors caused or contributed to abuse and neglect:

a. Staff abusers including nurses, teachers and other staff, exploited the extreme power imbalance between staff and disabled children, young people and adults.

b. Peer abusers exploited inadequate staff supervision of disabled children, young people and adults, and a lack of staff resources.

c. Survivors who were non-speaking and could not easily report their abuser, or who had a physical disability so could not physically escape their abuser, were at greater risk of abuse and neglect.

d. Some bystanders witnessed abusive practices but were too fearful to do anything about it or did not believe anything would be done if they did report abuse and neglect.

32. The following institutional factors caused or contributed to abuse and neglect:

a. Survivors were isolated from their whānau, and there was an absence of meaningful support for whānau to care for their loved ones outside the institution. In particular, whānau hauā Māori survivors were isolated from their whānau, hapū and iwi.

b. Individual needs of disabled children, young people and adults were not comprehensively identified or met at the Kimberley Centre, and in many cases, those needs were neglected.

c. The Kimberley Centre was over-regimented, and its institutional culture prioritised institutional order and routines over individual needs. Disabled children, young people and adults had little or no choice over any aspect of their daily lives.

d. The Kimberley Centre had a culture of institutional care which included the physical layout of the institution, the segregation of disabled children, young people and adults from family and society, and group rather than individualised care.

e. Data and record keeping was inadequate. Complaints were not recorded.

f. The Kimberley Centre was understaffed. Staff lacked relevant qualifications and expertise and were not properly trained for their positions of trust. It is unclear if any vetting procedures were in place for staff.

g. The lack of staff with lived experience of disability or close personal connection with disabled people contributed to the dehumanising environment, where disabled people were treated as lacking in agency and capacity.

h. Institutional racism and discrimination were prevalent against whānau hauā Māori and disabled Pacific Peoples children, young people and adults at Kimberley.

i. Lack of understanding and use of te ao Māori and Pacific Peoples views and practices on caring for disabled people was compounded by the lack of Māori and Pacific staff at the Kimberley Centre.

j. The Kimberley Centre lacked a complaints policy, and when complaints were made management failed to properly investigate and respond.

k. Management failed to hold staff accountable for abuse and neglect, and in some cases covered up serious events.

l. Failures to report or refer complaints involving serious allegations to NZ Police for investigation and prosecution meant survivors were denied access to justice.

m. There was a lack of monitoring and oversight of those in care. These safeguarding failures contributed to three choking deaths within a two-year period.

33. The following systemic, and practical factors caused or contributed to abuse and neglect:

a. The State policy of institutional care contributed to the separation, segregation and congregation of people with disabilities in psychopaedic institutions such as the Kimberley Centre, where they and their abuse and neglect became invisible.

b. Entrenched ableist attitudes of staff and systems ensured that disabled children, young people and adults at the Kimberley Centre and other psychopaedic institutions were viewed as incompetent, uneducable and unchangeable, which normalised abuse and neglect.

c. The State failed to hold itself, the institutions and abusers to account for the systemic abuse and neglect of disabled children, young people and adults at the Kimberley Centre.

34. The following societal factors caused or contributed to abuse and neglect:

a. The history of eugenics and the widespread societal attitudes of ableism and disablism including prejudice and discrimination against disabled people continued in the institution.

b. Societal attitudes that were ignorant of te Tiriti, including the principle of active protection of Māori language and culture, were reflected in the institution. Māori culture, heritage and language were suppressed and discouraged.

Other findings

Redress-related findings

35. Most of the Kimberley survivors the Inquiry heard from have not sought redress, and some have difficulty even contemplating their right to redress. Many will not have known that they could seek redress from the State.

36. The Ministry of Health has failed to offer most Kimberley Centre survivors fair redress for the abuse and neglect they suffered.

Crown failure to act decisively on implementing community living for people with a learning disability

37. Successive governments could and should have acted more quickly to close down the Kimberley Centre once the Government in 1985 had adopted a policy of community living and should have provided adequate funding and support to whānau and communities.