1. This part of the report explains why abuse and neglect happened to children, young people and adults in the care of the State and faith-based institutions during the Inquiry period, and who was responsible. It identifies the factors which caused or contributed to abuse and neglect in care, the lessons learned and the changes made, as required by clauses 31(b) and 31(e) of the Terms of Reference. It also responds to clause 33 in terms of making findings of fault and whether standards were breached.

2. Chapter 2 talks about survivors, the personal factors that safeguarded them and the factors that contributed to their entry into care and abuse and neglect once they were in care. This chapter also looks at the factors relating to abusers and staff and carers who saw or knew about abuse and neglect.

3. Chapters 3 to 6 set out the factors across State and faith-based care settings that contributed to abuse and neglect. These chapters focus on:

• the relevant standards that applied in care settings, and related policies, rules and practices (chapter 3)
• the vetting, recruitment, training and development, performance management and supervision of staff and carers (chapter 4)
• the complaints processes that were available to people in care, the processes in place for responding to complaints and how effective these were (chapter 5).
• the oversight and monitoring of care settings and people in care, and whether it was effective at preventing and responding to abuse and neglect

4. Senior leaders and managers within care settings are brought into focus in these chapters, with a close look at how their individual decisions and actions or inactions contributed to abuse and neglect in care. Their role and responsibilities to manage the people (staff, carers, and people in care), processes and risks is also discussed.

5. Chapter 7 brings together the factors identified in chapters 3 to 6 and concludes why abuse and neglect happened at the institutional level of care.

6. Chapter 8 discusses faith-based institutions and the factors specific to why children, young people and adults in their care experienced abuse and neglect.

7. Chapter 9 describes why the State failed to safeguard people in care and what it should have done when it knew survivors were experiencing abuse and neglect.

8. Chapter 10 explains the role of societal attitudes in abuse and neglect in care.

9. Chapter 11 sets out the Inquiry’s conclusion on why abuse and neglect in State and faith-based care happened during the Inquiry period.

10. Chapter 12 sets out the Inquiry’s key findings on breaches of te Tiriti o Waitangi and its principles, breaches of standards of care, the factors which contributed to abuse and neglect, who was at fault for abuse and neglect, and the lessons learned and changes made during the Inquiry period.