1181. Clause 31(a) of the Terms of Reference requires the Inquiry to make findings on the nature and extent of abuse that occurred during the Inquiry period.

1182. The Inquiry finds:

a. The best available estimates indicate that up to 200,000 people were abused in care between 1950 and 1999. Precise figures are impossible due to data inadequacies and poor records kept by the State and faith-based institutions, the passage of time, barriers to disclosure, abuse going unreported, and steps commonly taken to conceal abuse. The total number may be higher than this estimate.
b. Many different forms of abuse and neglect were reported to the Inquiry. These included;

i. entry into care caused trauma
ii. psychological and emotional abuse and neglect
iii. physical abuse and neglect
iv. sexual abuse; racial abuse and cultural neglect
v. spiritual and religious abuse and neglect
vi. medical abuse and neglect
vii. solitary confinement
viii. financial abuse and forced labour
ix. educational neglect.

c. Sexual, physical and emotional abuse were the most common forms of abuse in care. Neglect was pervasive across all care settings and varied according to the setting.
d. People experienced racism in all care settings.
e. Policies and practices that would now be understood as ableist and disablist were common across all settings.
f. In some residential and institutional care settings, some children, young people and adults in care experienced the over-use of seclusion, over-medicalisation, lobotomies, sterilisation, invasive genital examinations and experimental psychiatric treatments without informed consent.
g. Abuse and neglect were pervasive in social welfare, Deaf, disability, and mental health residences and institutions.
h. State care, particularly in social welfare residences and institutions, often usedpunishment and control rather than care.
i. Tamariki, rangatahi and pakeke Māori placed in Pākehā value-based institutions often experienced severe abuse and neglect including patu (hitting/striking), whakamamae (inflicting pain) and whakarere (neglect). This was a transgression against whakapapa, personal tapu, mana, mauri and wairua.
j. Some survivors endured extensive and extreme abuse and neglect. At times, surviving severe physical pain and / or mental suffering.
k. From the over 2,300 survivors who spoke to the Inquiry:

i. many survivors experienced multiple forms of abuse and neglect, for example, 82 percent of survivors who spoke to us about sexual abuse also reported physical abuse
ii. abuse and neglect were particularly prevalent in social welfare settings, faith settings (particularly Catholic, Anglican, and Gloriavale) and disability and mental health settings
iii. residential and institutional care in social welfare, education and health and disability care settings typically had highly regimented systems. These types of institutions had high levels of physical abuse. The highest levels of physical abuse were reported at Wesleydale Boys’ Home and Ōwairaka Boys’ Home, both in Tāmaki Makaurau Auckland
iv. tamariki, rangatahi and pakeke Māori were more likely to experience neglect compared to non-Māori children, young people and adults in care.
v. children aged 10-14 endured high levels of sexual and physical abuse
vi. Māori and Pacific survivors endured higher levels of physical abuse than other ethnicities
vii. disabled survivors suffered higher levels of all forms of abuse than non-disabled survivors
viii. Deaf and disabled survivors were more likely to report physical, emotional and sexual abuse than other forms of abuse
ix. a higher proportion of survivors in faith settings than in State care were sexually abused. The highest reported levels of sexual abuse were at Dilworth school in Tāmaki Makaurau Auckland (Anglican), Marylands School in Ōtautahi Christchurch (Catholic) and at Catholic institutions in general
x. children and young people in foster care experienced the highest levels of sexual abuse among social welfare care settings
xi. the decade with the highest rates of abuse and neglect was the 1970s, followed by the 1960s and then the 1980s
xii. some survivors reported the misuse of solitary confinement or seclusion
xiii. male survivors reported higher levels of abuse than females, including sexual abuse. Males experienced higher levels of physical abuse than other forms of abuse
xiv. female survivors were more likely to experience emotional and sexual abuse, compared to other forms of abuse. Females experienced higher levels of neglect compared to males.

l. At the Lake Alice Child and Adolescent Unit, as set out in the Inquiry’s interim report Beautiful Children, abuse included:

i. electric shocks and injections of paraldehyde as punishment, administered to various parts of the body including the head, torso, legs and genitals
ii. the misuse of solitary confinement 
iii. patients exposed to unreasonable medical risks

Beautiful Children: Inquiry into the Lake Alice Child and Adolescent Unit

m. At Marylands School and Hebron Trust, as detailed in the Inquiry’s interim report Stolen Lives, Marked Souls:

i. abuse and neglect was extensive and extreme
ii. sexual abuse was pervasive
iii. physical, emotional, and psychological abuse led to some survivors living in perpetual fear
iv. evidence suggests the abuse was used as punishment as well as to intimidate
v. there was pervasive neglect including neglect of basic needs as well as cultural, medical, and emotional needs
vi. children and young people suffered mental and physical pain
vii. cultural and religious abuse was extensive
viii. survivors experienced racism.

Stolen Lives, Marked Souls: The inquiry into the Order of the Brothers of St John of God at Marylands School and Hebron Trust

n. At Te Whakapakiri Youth Programme on Aotea Great Barrier Island, as detailed in the Inquiry’s case study:

i. abuse and neglect were pervasive and extreme
ii. young people experienced severe physical violence
iii. young people were sent alone to an isolated island for days at a time as punishment
iv. there is evidence of young people being threatened with death through mock executions.

Boot Camp: Te Whakapakari Youth Programme – A case study of State-funded violence and abuse of children and young people needing care and protection

o. At the Kimberley Training Centre near Taitoko Levin, as detailed in the Inquiry’s case study:

i. disabled children, young people and adults suffered severe and chronic abuse and neglect;
ii. physical and sexual abuse of disabled children, young people and adults was pervasive and severe
iii. physical abuse was common and normalised. This was reflected by the ‘Kimberley cringe’ where survivors would cower and protect their head if they were approached quickly
iv. people experienced extreme neglect of their physical, emotional, psychological, educational, medical, and dental needs
v. nutritional practices were poor with some disabled children, young people and adults not fed for long periods or fed with feeding tubes that were later assessed as not medically required
vi. the physical environment 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 purposeful activity

Out of sight, out of mind: Kimberley Centre – A case study of the Kimberley Centre, a ‘psychopaedic’ institution for people with a learning disability

p. At Kelston School for Deaf in Tāmaki Makaurau Auckland, and Van Asch College in Ōtautahi Christchurch, as detailed in the Inquiry’s case study:

i. Deaf students experienced regular sexual, physical, verbal and psychological abuse;
ii. physical violence was normalised and pervasive;
iii. all Deaf children and young people experienced linguistic abuse and neglect and language suppression
iv. Deaf children and young people were punished for using Sign Language and their Deaf culture and identity were not supported.

Our hands were tied: Van Asch College and Kelson School for the Deaf – A case study of audism abuse at Deaf Schools

q. At Hokio Beach School in Taitoko Levin and Kohitere Boys' Training Centre in Taitoko Levin, as detailed in the Inquiry’s case study:

i. there were cultures of normalised and pervasive violence, with many experiencing severe corporal punishment, sometimes inflicted with weapons and to the genitals
ii. staff condoned and encouraged peer-on-peer violence through a king-pin system including violent ‘stomping’ initiations of new boys
iii. sexual abuse was pervasive
iv. solitary confinement was misused
v. racism and cultural abuse was normalised
vi. staff punished boys with extreme physical training and inhumane tasks, often physically assaulting them at the same time.

Cauldron of Violence: Hokio Beach School and Kohitere Boys' Training Centre – A case study on the State's role in creating gangs and criminals