135. Under the Inquiries Act 2013, the Inquiry could conduct its work as it considered appropriate, in line with the directions in the Terms of Reference and in the Act.[99]

Tā te tangata whai wāhi ki te Kōmihana
How people engaged with the Inquiry

136. The Inquiry heard from survivors, witnesses, whānau, hapū, iwi and hāpori Māori, rōpū Māori, Pacific Peoples, Deaf, disabled people and people who experience mental distress, advocates, social service providers, people in prison, gang whānau, academic and legal experts, former and current government officials, current and former staff of care facilities, and individuals and representatives from faith-based institutions. The diagram below summarises the many and varied ways that people engaged with the Inquiry. Data is from 1 January 2019 to 31 May 2024.

How people engaged with the Inquiry

• Visits to the Inquiry website = More than half a million
• Number of email enquiries to contact centre = More than 50,000
• Number of phone calls received by contact centre = More than 14,500
• Number of text messages enquiries to the contact centre = More than 1,000
• Survivor-led face-to-face interviews (private sessions) = 1,630
• Sworn witness statements from or on behalf of survivors = 1,176
  
  • Sworn witness statements from survivors taken by the Inquiry = 603
  • Sworn witness statements from survivors taken with help from a lawyer = 573
• Witness accounts from survivors = 218
• Community engagements = 126, reaching 2,025 participants
  
  • Disabled people 456
  • Māori 779
  • Pacific Peoples 241
  • Rangatahi 44
  • Gang whānau 425
  • Takatāpui, Rainbow and MVPFAFF+ 90
  • Incarcerated 98
• Regional haerenga (number of participants and locations) = 29 community events, reaching 650 participants
• Wānanga = 300 participants
• Fono and talanoa = 9 fono and talanoa, reaching more than 230 participants
• Public hearings = 15 public hearings over 133 days and including more than 270 witnesses
• Unique views of public hearings’ online streams = More than 145,800
• Advisory groups = 5 advisory groups, 192 meetings
• Reference groups = 9 reference groups, 116 meetings
• Community conversations = 6 groups, (met 5 times, approximately 5 people per meeting) including Deaf people, disabled people who experience mental distress
• Town hall meetings and community events = More than 53 events held
• Number of pānui distributed approximately = 60 pānui to more than 2,500 recipients
• Number of kaupapa Māori external providers and intermediaries that assisted to identify survivors = More than 20
• Wellbeing and hauora organisations that assisted in supporting survivors = More than 100

Ngā tukanga tūhono ki ngā purapura ora
Approach to engaging with survivors

137. The Inquiry could not have undertaken its work without the generosity of survivors in sharing their experiences. The Inquiry invited all survivors of abuse and neglect in State or faith-based care to get in contact.

138. The Inquiry acknowledges that many survivors did not, and will never, come forward to share their experience. For many, the trauma and pain was too great. Many survivors face multiple barriers to coming forward arising from mistrust in authorities, communication barriers, cultural shame, family shame, racism, sexism, ableism and homophobia.

139. Survivors could engage with the Inquiry in person, through their whānau, through legal representatives or advocates, during community meetings or wānanga. They did not need to register with the Inquiry to participate. They could provide as little or as much information as they wanted to. They could remain anonymous if they wished.

140. Survivor Faithful Disciple (NZ European), who was born into the Gloriavale community, echoed the feelings of many survivors when he told the Inquiry:

“My primary motivation in engaging with the Royal Commission is to play my part in ensuring that no one suffers as I did”.[100]

141. Survivors came forward from across Aotearoa New Zealand and overseas. By the end of the Inquiry, 3,827 survivors of abuse in State and faith-based care had registered with the Inquiry, and 2,329 survivors shared their experiences. Pākehā survivor Mr NV, who was 7 years old when he started at Marylands School (Catholic, Ōtautahi Christchurch), told the Inquiry why it was important for him to share experiences of abuse and neglect in care:

“It is hard for me to confront all this. Even so, I am providing this evidence because I know that I need to speak up for myself, and for my mates who didn’t make it. It’s time that the Government finally owned up to what happened to us while we were in care. There isn’t any chance of me being able to move on and put this all behind me until that happens.”[101]

142. The health, wellbeing and mana of survivors was at the centre of the Inquiry’s approach and it always sought to avoid further harm. Interactions with survivors and their whānau or support networks were trauma informed. This meant being sensitive to the impacts of trauma and treating survivors and their whānau with atawhai (kindness), humanity, compassion, dignity, respect and generosity.[102]

143. The Inquiry respected the mana motuhake (autonomy) of survivors and empowered them to make their own decisions about how they would be involved. The Inquiry considered survivors’ requests to stay anonymous and, where appropriate, made orders banning the publication of their names and other identifying details.[103]

144. The Inquiry established a hauora policy and a survivor hauora team. Their role was to contact survivors to appropriately support them before, during and after they engaged with the Inquiry. Survivors and their whānau had access to wellbeing support and services provided by counsellors, social workers, psychologists, psychotherapist, nurses and rongoā Māori practitioners. These services were provided free of charge to survivors and whānau (as envisaged in the Inquiry Terms of Reference).[104]

145. Some survivors shared their experiences as a group, community, collective or whānau. The Inquiry heard from siblings who had survived care together and from children of survivors. It heard from people on behalf of loved ones who could not share their own experiences because, for example, they were too distressed to do so, or have passed away. The Inquiry spoke with groups of survivors in prison, in psychopaedic and psychiatric hospitals (including forensic settings) and related services for disabled people.

146. Survivors could meet privately with a commissioner or kaitakawaenga (a representative of the Inquiry). The Inquiry held 1,630 face to face sessions with survivors. Kaitakawaenga were experienced people with mana and community standing from a wide range of backgrounds to ensure that survivors would have an opportunity to talk to the Inquiry if they wished. Face to face interviews were held with survivors in prison. Online interviews were held with survivors who live overseas. The Inquiry stopped hearing private sessions on 30 June 2023.

Private sessions held with registered survivors

Year	Number of private sessions held
2019	286 private sessions
2020	330 private sessions
2021	332 private sessions
2022	492 private sessions
2023	200 private sessions

147. Survivors could bring whānau or other support to private sessions and group engagements. The Inquiry provided culturally appropriate wellbeing support before, during and afterwards. Survivors were assured the information shared would be used only with their consent.

148. Although survivors did not need to have a lawyer to participate in the Inquiry, funding was provided funding for them to seek assistance from a panel of independent lawyers if they wished. This assistance could include legal representation, legal advice or help (for example, with drafting documents). About one third of survivors who participated in the Inquiry received funded legal assistance.

149. The Inquiry received 1,545 witness statements, including:

• 1,176 witness statements from survivors, or on behalf of survivors (including 573 witness statements provided with help from legal assistance lawyers)
• 171 witness statements on behalf of the State, faith-based institutions or other organisations
• 80 witness statements from experts
• 46 witness statements from current or former staff or caregivers
• 65 witness statements from people who witnessed abuse and neglect
• 7 witness statements from former members of Parliament.

150. While the Inquiry aimed for best practice, lessons were identified during the Inquiry process. The way the Inquiry worked with survivors, their whānau and support networks was revised and updated as it progressed. In 2021, the Inquiry reviewed and updated its survivor wellbeing policy to improve its cultural appropriateness. Working with a hauora Māori clinical expert, the Inquiry adopted a revised survivor wellbeing approach that was mana informed.

151. Some survivors who came forward told the Inquiry about experiences that may have fallen outside the scope of Terms of Reference, such as abuse or neglect in private settings. Those experiences are not described in this report but the Inquiry acknowledges the bravery those people showed in sharing their stories.

152. The Inquiry recognises that some survivors of abuse in State and faith-based care were not aware that the Inquiry existed, and some survivors may have found it difficult to get in contact.

I noho ngā hui ōkawa a te Komihana hei ara kōrero tūmatanui
The Inquiry’s public hearings were an opportunity to talk publicly

153. The Inquiry held more than 133 days of public hearings from June 2019 to October 2022. Most of these were held in person and streamed live online. Hearings gave survivors an opportunity to talk publicly about what happened to them and witnesses of abuse to describe what they saw or heard. It also provided an opportunity for the Inquiry to publicly hold State and faith-based institutions to account. Some evidence was so sensitive that hearing sessions were closed to the public and media. Some survivors chose to give all or part of their evidence anonymously, from a different room, without cameras and / or with voice distortion. The Inquiry did accessibility assessments and made changes to improve accessibility. Legal assistance and wellbeing support were available to all witnesses before, during and after each hearing.

154. The public hearings were grouped into themes, specific care settings and groups of survivors. The Inquiry heard evidence from survivors, advocates, academic and legal experts, government officials and individuals and representatives from faith-based institutions.

Public hearings held by the Inquiry

Hearing	Dates	Theme
Preliminary Hearing	25 June 2019	The Inquiry’s scope, focus and procedures
Contextual Hearing	29 October to 8 November 2019	The overarching contextual circumstances of abuse and neglect in care
State Redress Hearing (Phase 1)	21 September to 2 October 2020	Experience of survivors of abuse and neglect in care about civil claims made against the State and civil litigation in the courts
State Redress Hearing (Phase 2)	19 October to 5 November 2020	Processes for resolving claims of abuse in State care
Faith-based Redress Hearing (Phase 1)	30 November to 12 December 2020	Experience of survivors seeking redress for abuse and neglect in the care of faith-based institutions
Faith-based Redress Hearing (Phase 2)	15 to 29 March 2021	Processes for resolving claims of abuse in faith-based care
State Children’s Residential Care Hearing	3 to 11 May 2021	Lived experience of children and young people who were abused and neglected in social welfare residential care
Lake Alice Child and Adolescent Unit Hearing	14 to 28 June 2021	Abuse and neglect at Lake Alice Hospital’s Child and Adolescent Unit
Tulou – Our Pacific Voices: Tatala e Pulonga (Pacific Peoples’ Experiences) Hearing	19 to 30 July 2021	Lived experiences of Pacific Peoples who were abused in State and faith-based institutions
Marylands School (St John of God) Hearing	9 to 17 February 2022	Abuse and neglect by the Hospitaller Order of St John of God religious brothers that occurred at Marylands School, St Joseph’s Orphanage and the Hebron Trust
Tō muri te pō roa, tērā a Pokopoko Whiti-te-rā (Māori Experiences) Hearing	7 to 18 March 2022	Lived experiences of whānau Māori who were abused and neglected in State and faith-based institutions
Foster Care Hearing	13 to 17 June 2022	Lived experiences of survivors who experienced abuse and neglect in foster care
Ūhia te māramatanga Disability, Deaf and Mental Health Institutional Care Hearing	11 to 20 July 2022	Lived experiences of survivors who are disabled, Deaf or were placed in psychiatric institutions
State Institutional Response Hearing	15 to 26 August 2022	Responses of State agencies to the abuse and neglect of children, young people and adults in care
Faith-based Institutional Response Hearing	13 to 31 October 2022	Responses of faith-based institutions to the abuse and neglect of children, young people and adults in care

155. Most hearings were held in Tāmaki Makaurau Auckland and chaired by Coral Shaw. Sir Anand Satyanand chaired the Contextual Hearing. Due to other Inquiry priorities or perceived conflicts of interest, not all Commissioners attended all hearings. Ngāti Whātua Ōrākei provided cultural guidance and support for the hearings, including opening and closing the sessions. The Inquiry removed legal formalities from public hearings, where possible, as directed by the Terms of Reference. Examples of this included on-site wellbeing specialists and holding some hearings at fale and marae.

156. The Inquiry’s Tulou – Our Pacific Voices: Tatala e Pulonga (Pacific Peoples’ Experiences) Hearing was conducted in accordance with Pacific protocols in the Fale o Samoa in Māngere, Tāmaki Makaurau Auckland. Commissioner Ali’imuamua Sandra Alofivae MNZM nurtured the vā (teu le vā) throughout the hearing. Tulou is a term commonly used in many Pacific languages to show courtesy when one comes within another’s personal space. It was used to acknowledge the voice and personal space of survivors and their families, while allowing the Inquiry to listen to and learn from their experiences. Tatala e pulonga is a Tongan metaphor meaning “lifting the dark cloud”. This metaphor is commonly used to demonstrate the lifting of darkness and, in this context, a dark history of abuse in care.

157. The Inquiry’s Tō muri te pō roa, tērā a Pokopoko Whiti-te-rā (Māori Experiences) Hearing was held at Ōrākei Marae in Tamaki Makaurau Auckland. Ngāti Whātua Ōrākei gifted the name, which refers to hope and healing for survivors of abuse in care, after years of darkness. This hearing was co-chaired by Commissioners Julia Steenson (Ngāti Whātua Ōrākei, Waikato-Tainui) and Dr Andrew Erueti (Ngā Ruahinerangi, Ngāti Ruanui, Te Āti Haunui-a-Pāpārangi) generally in person from Ōrākei Marae. Due to COVID-19, some Commissioners attended this hearing online. This hearing was not open to general public attendance and was livestreamed.

158. Commissioner Paul Gibson co-chaired the Inquiry’s Ūhia te māramatanga Disability, Deaf and Mental Health Institutional Care Hearing. The Inquiry made changes to improve accessibility. Hearing assistance was available in the public hearing room, and the hearing was streamed live online with New Zealand Sign Language interpreters.  People who wanted to submit questions or submissions in New Zealand Sign Language could use videomail.

Ka rere te wā, ka whanake te tūhonotanga
Engagement developed and increased over time

159. Engagement with survivors, whānau and their communities was a critical part of the Inquiry. This included Māori, Pacific Peoples, Deaf people, disabled people and people who experience mental distress. As the Inquiry progressed and learned more about how to connect with people in ways that were appropriate and safe for them, its engagement methods improved. The Inquiry sought to interact with people on their own terms. The Inquiry met with survivors in prisons across the motu (country). The Inquiry communicated regularly through a digital and printed pānui, website, digital engagement tool, mainstream media and social media.

160. The Inquiry ran online group community conversations to remove barriers to accessibility for Deaf survivors, disabled survivors and survivors who experienced mental distress. Multiple hui were held with people from Takatāpui, Rainbow and MVPFAFF+ communities and organisations that support them.

161. Commissioner Paul Gibson co-chaired the Inquiry’s Ūhia te māramatanga Disability, Deaf and Mental Health Institutional Care Hearing. The Inquiry made changes to improve accessibility. For example, counsel and commissioners provided visual descriptions of themselves before speaking as protocol to enable equity for blind or low vision attendees, the public space had hearing loops and New Zealand Sign Language interpreters were part of the live stream. People who wanted to submit questions or submissions in New Zealand Sign Language could use videomail. 

162. Commissioners went on haerenga (journeys) to Kaitāia, Kaikohe, Waikato, Tūranganui-a-Kiwa Gisborne, Ōtautahi Christchurch, Ōtepoti Dunedin, Te Tai Poutini West Coast, Waihōpai Invercargill and Motupōhue Bluff to engage particularly with survivors (communities including iwi), leaders and providers of care in these places.

163. A gang whānau hui was held in February 2023 and the Royal Commission was invited to attend. The hui provided a platform for gang whānau (nine gangs and more than 250 participants) to share with the Inquiry their experiences of abuse and neglect in care and their views on its connection to gang membership. Two female focus groups were also held to hear their unique experience. The Inquiry offered one-on-one interviews for gang whānau who were survivors of abuse and neglect in care.

164. Many in-person engagements had to be paused or cancelled during the COVID-19 pandemic. The Inquiry moved to online engagements if participants were comfortable with this.

I tuku kupu āwhina ngā rōpū āwhina me ngā rōpū whakatairite
Advisory and reference groups provided advice

165. The Inquiry’s Terms of Reference directed it to focus on victims and survivors, partner with iwi and Māori, work inclusively with Pacific Peoples, and ensure that disabled people and people who experience mental distress could participate in the Inquiry.[105] The Inquiry set up a Survivor Advisory Group of Experts. The number of members and its role changed over time. By late 2021, it provided strategic advice and feedback on the Inquiry’s work as well as guidance and support on engaging with survivors. The group provided feedback on drafts of the Inquiry’s interim and final reports.

166. The Inquiry brought together Te Taumata, a group of Māori leaders and pukenga (experts). Its role changed over time. By early 2022 its function was to ensure that the Inquiry had implemented an effective te Tiriti-based approach. Te Taumata provided strategic advice and guidance on engaging with iwi, hapū, whānau, and hapori Māori.

167. In late 2021, the Inquiry extended its approach to include regular meetings with:

• Pou Tikanga (a group of tikanga and te reo Māori experts) was set up in 2021 to provide advice guidance on tikanga-based approaches to the Inquiry
• two groups that had formed independently of the Inquiry to discuss issues of shared importance and seek their feedback and advice:
  • Te Ara Takatū – a group of Māori-led survivors, kaupapa Māori advocates and academics
  • the Royal Commission Forum – a group of survivors, advocates and academics
• a small reference group of survivors, academics and experts that provided feedback on the interim report Beautiful Children: Inquiry into the Lake Alice Child and Adolescent Unit.

168. In 2022, the Inquiry engaged groups of specialist advisors. This involved bringing together reference groups with people with lived or academic expertise in Deaf culture, disability, faith, rangatahi, Pacific Peoples, Takatāpui, Rainbow and MVPFAFF+, mental distress and social welfare issues.

169. All advisory, reference groups and Pou Tikanga were provided with draft material, in confidence, to provide expert feedback for consideration in the finalisation of the reports.

Tā te Kōmihana tūhura i ngā tūkinotanga i ngā pūnaha taurima
How the Inquiry investigated abuse and neglect in care

I whanake te tukanga tūhura
The investigative approach evolved over time

170. As the scope set out in the Terms of Reference was so broad, the Inquiry had to make difficult choices about what could be investigated in depth within the timeframe and resources available. The Inquiry’s investigative approach evolved in response to what survivors shared, and as evidence of abuse and neglect in care was uncovered.

171. The Inquiry developed criteria, which were publicly available on its website, for selecting investigation topics. These included the extent that the investigation would:

• address the matters in the Terms of Reference
• respond to information from investigations, survivor accounts and research
• respond to areas of particular concern among survivors advocates and / or the public
• identify areas most likely to lead to meaningful recommendations.

172. The Inquiry’s investigation of abuse and neglect in faith-based care is illustrative of the evolution of its approach. The Terms of Reference directed the Inquiry to examine abuse and neglect in faith-based care, but it did not list specific faith-based institutions or care settings. The Inquiry could not investigate all faiths practising in Aotearoa New Zealand to the same extent. The Inquiry started its investigations into abuse in faith-based institutions with separate investigations into abuse in the care of the Catholic Church and the Anglican Church. The Inquiry’s redress investigation, which involved the Catholic Church and the Anglican Church, also included The Salvation Army within its scope.

173. The Anglican Church investigation was formally expanded in 2022 to include the Presbyterian Church, the Methodist Church and The Salvation Army (Protestant faiths) as well as other faiths, including the Gloriavale Christian Community, Plymouth Brethren Christian Church (formerly known as Exclusive Brethren) and Jehovah’s Witnesses.[106] These changes stemmed from increased numbers of survivors coming forward to disclose abuse and neglect in the care of these faiths and their institutions, including schools and care homes.

174. The Inquiry investigated abuse and neglect in specific State and faith-based care settings, as well as specific themes and issues:

• abuse and neglect in the care of the Catholic Church
• abuse and neglect in the care of Protestant and other faiths, including the Anglican Church, Presbyterian Church and Presbyterian Support Organisations, Methodist Church, The Salvation Army, Gloriavale Christian Community, Plymouth Brethren Christian Church and Jehovah’s Witnesses
• abuse and neglect in State psychiatric care
• Deaf people’s experiences of abuse and neglect in care
• disabled people’s experiences of abuse and neglect in care
• abuse and neglect in foster care
• Māori experiences of abuse and neglect in care
• Pacific Peoples’ experiences of abuse and neglect in care
• abuse and neglect in children’s State residential care
• State and faith-based redress
• abuse and neglect in State youth justice care.

175. The Inquiry initially intended to produce a separate interim report for each of these investigations.[107] As evidence emerged, and the Inquiry's investigative approaches evolved, it became clear that the investigations shared many common features. The Inquiry decided to produce a single final report covering all its investigations, and two interim reports highlighting the abuse and neglect experienced by survivors in the care of the Catholic Church (Stolen Lives, Marked Souls: The inquiry into the Order of the Brothers of St John of God at Marylands School and Hebron Trust) and in State psychiatric care (Beautiful Children: Inquiry into the Lake Alice Child And Adolescent Unit).

176. The Inquiry was not able to comprehensively investigate abuse and neglect in every care setting included in the Terms of Reference. For example, there were not separate investigations on abuse in transitional and law enforcement settings. While the Inquiry investigated abuse and neglect in some private and State integrated schools, it could not investigate abuse in all educational settings. However, this report does record specific disclosures of abuse and neglect by survivors of care in all settings within the Terms of Reference.

He nui ngā whakamārama me ngā taunakitanga i kohia
A large amount of information and evidence was collected

177. The information and evidence used by the Inquiry included transcripts, survivor accounts and community engagements, witness statements, transcripts from public hearings, international and domestic reports and reviews, evidence and findings from previous inquiries,[108] the Waitangi Tribunal, meeting notes, email records, police records, medical records, ministerial briefings and Cabinet papers.

178. Information and evidence was gathered through submissions, public hearings, requests and orders to produce information from State and faith-based institutions, roundtables, wānanga, hui and fono, research and policy analysis.

179. In March 2019 the Inquiry issued a preservation of documents order that prohibited State and faith-based institutions from destroying potentially relevant information.[109] The Inquiry issued more than 500 requests for information to State and faith-based institutions and received more than 1.1 million documents.

I tautoko te rangahautanga me te tātaritanga i ngā mōhiotanga me ngā taunakitanga
Research and analysis supplemented the information and evidence

180. The Inquiry conducted research and analysis to better understand the nature, extent and impact of abuse and neglect, and develop evidence-based recommendations. Some research was commissioned from external research groups and experts and some was undertaken in house. Key research reports were published on the Inquiry website.

181. The research and analysis covered a wide range of subjects critical to the Inquiry’s investigations, including:

• Māori pathways into care and experiences of abuse in care[110]
• the link between State care and eventual criminal custody[111]
• disabled people’s experiences in care[112]
• issues faced by survivors of abuse in care when seeking cover, compensation and rehabilitation from the Accident Compensation Corporation (ACC)[113]
• the economic cost of abuse in care[114]
• estimates of the number of survivors and levels of abuse in State and faith-based care[115]
• societal attitudes to ‘juvenile delinquency’ and pathways into care
• experiences of seclusion and solitary confinement in care
• attitudes of the medical and psychiatric profession towards treatment of LGBTQIA+ people in the 1970s
• physiological impacts of maltreatment on the adolescent brain[116].

Ngā whakaritenga ki te whakapūmau i te motuhaketanga, te tōkeketanga me te matatikatanga
Measures to ensure independence, impartiality and fairness

182. The Inquiry was independent from the Government. The Commissioners ensured their independence and impartiality through various measures including a transparent conflict of interest policy and independent advice. The Inquiry had premises and computer systems that were separate from the Government.

183. The Inquiry undertook a comprehensive process before finalising each interim report and this final report to ensure fairness and balance. This process included providing copies of relevant sections of the draft reports along with the evidence the Inquiry was relying on to make unfavourable findings. The Inquiry received large amounts of feedback and commentary, even from parties who had acknowledged or accepted unfavourable findings against them through earlier processes, such as in public hearings. For example, the Inquiry received over 1600 pages of feedback in table format from over 100 organisations and individuals in the natural justice process for this final report.

184. Although the Inquiry could not make decisions about civil, criminal or disciplinary liability, it could make unfavourable findings about people or institutions. As required by the Inquiries Act, where the Inquiry planned to make unfavourable findings against a person or institution, the relevant person or institution was given an opportunity to respond and comment before the findings were finalised.

185. The Inquiry carefully considered comments and feedback and, where appropriate, made changes including to correct inaccuracies. In some instances, information was deleted or added to the reports to provide balance.

186. Under the Inquiries Act, certain people and institutions could apply to be core participants, with the right to have their say through giving evidence and making submissions.[117] Survivors could choose to apply to become a core participant but did not need to do so to participate.

187. Other processes the Inquiry followed to ensure impartiality, fairness and accuracy included:

• initially seeking consent to use quotes or information and then reconfirming consent if a quote or identified information was to be included in interim reports or the final report
• giving notice, and copies or extracts of witness statements, to people or institutions who were going to be criticised by witnesses at hearings
• giving people or institutions an opportunity to identify if any documents the Inquiry intended to refer to in its reports were legally privileged, which means that they could not be used without permission
• seeking feedback on some of the draft minutes documenting the Inquiry’s processes, procedures and decisions before they were finalised.

He tepenga tō ētahi o ngā raraunga
Some of the data had limitations

188. One of the purposes of the Inquiry, as directed in the Terms of Reference, was to identify, examine and report on the extent of abuse and neglect in State and faith-based care.[118] The true extent of abuse and neglect in care has proved difficult to calculate. Part 4 explains how historical data and record keeping by State and faith-based institutions was inadequate.

189. International inquiries sometimes took a more research-based approach to collecting information. International inquiries asked survivors to fill out detailed surveys. Having learnt from these the Inquiry decided to take a less formal and more trauma-informed approach to make sure, as far as possible, that the process of sharing their experiences did not re-traumatise survivors. Survivors were encouraged to use their own words to describe what happened to them.

190. The Inquiry’s decision to take a trauma-informed approach meant that that the direct information collected was more difficult to analyse straight away than it would have been if a data-driven approach was followed. The Inquiry met this challenge by setting up a team to review transcripts and written submissions to identify relevant data (for example, the institution in which a survivor was in care, or if they experienced solitary confinement). The Inquiry also used a digital tool (a natural programming language) to extract data. These processes resulted in a more accurate set of data, from registered survivors’ evidence on the nature, extent and impact of abuse and neglect in State and faith-based care in Aotearoa New Zealand.

Tā te Kōmihana whakatau i āna tūtohitanga
How the Inquiry developed its recommendations

191. The Terms of Reference required the Inquiry to provide recommendations, which may include legislation, policy, rules, standards and practices, on:

• any appropriate changes to the existing redress processes for survivors who have suffered abuse and neglect in State or faith-based care
• any other appropriate steps the State or faith-based institutions should take to address the harm caused
• changes to be made in future to ensure that the factors that allowed abuse and neglect to occur do not persist.[119]

192. The Inquiry asked survivors what their hopes and vision for the future were. Survivors shared more than 3,000 potential solutions, all with the hope that abuse and neglect in care will never happen again. Their proposed solutions helped commissioners to form recommendations.

193. State and faith-based representatives engaged with the Inquiry on proposed redress solutions. The Inquiry invited representatives from the State and faith-based institutions to propose other solutions, but State representatives declined. The Inquiry tested some ideas underpinning some recommendations with the State and faith-based institutions before they were finalised.

Me pānui tahi i ngā rīpoata a te Kōmihana kia mārama ai te whānuitanga o ngā kōrero
The Inquiry’s reports should be read together for a complete picture

194. This report is the final in a series of reports the Inquiry has produced. The reports should be read in full to understand the overall picture of abuse in State and faith-based care from 1950 to 1999.

195. The Inquiry Terms of Reference directed it to produce three interim reports and one final report. It could issue other interim reports as it saw fit.[120]

196. The Inquiry’s publications became more accessible over time as communities provided accessibility feedback. The Inquiry started publishing executive summaries of its interim reports in te reo Māori, Samoan, Cook Islands Māori, Niuean, Tongan, Tokelauan, New Zealand Sign Language, Easy Read, large print, braille, audio and video.

Report	Summary
Tāwharautia: Pūrongo o te Wā: Interim Report (Volume 1) and Survivor Voices (Volume 2) Delivered: December 2020	The Inquiry’s progress, and key themes and common issues heard by the Inquiry from survivors
Pūrongo Whakahaere: Administrative Report Delivered: December 2020	An estimate of the additional workload, cost and time the Inquiry needed to fully answer the Terms of Reference
He Purapura Ora, he Māra Tipu: From Redress to Puretumu Torowhānui Delivered: December 2021	Findings about how State and faith-based institutions responded to survivors’ efforts to obtain redress. Recommendations for a new scheme to address the harm suffered by survivors of abuse in care.
Beautiful Children: Inquiry into the Lake Alice Child and Adolescent Unit Delivered: December 2022	The abuse and neglect suffered by children and young people admitted to Lake Alice’s Child and Adolescent Unit from 1972 to 1980
Stolen Lives, Marked Souls: The inquiry into the Order of the Brothers of St John of God at Marylands School and Hebron Trust Delivered: July 2023	The abuse and neglect experienced by survivors of the Catholic Order of St John of God at Marylands School and Hebron Trust in Ōtautahi Christchurch

 

Footnotes