Ngā takahi paerewa
Breaches of relevant standards

879. Clause 33 of the Terms of Reference allows the Inquiry to make findings that relevant standards have been breached. In summary, during the Inquiry period the Inquiry finds:

Ngā takahi i te Tiriti o Waitangi
Breaches of te Tiriti o Waitangi

a. Te Tiriti o Waitangi guaranteed rights to Māori throughout the Inquiry period that should have been protected and upheld.
b. The Crown deprived whānau, hāpu and iwi of exercising tino rangatiratanga over their kāinga (home), to care and nurture the next generation and regulate the lives of their people, and that this breached the principle of active protection in te Tiriti o Waitangi.
c. The Crown’s failure to address the on-going effects of colonisation that contributed to tamariki, rangatahi and pakeke Māori being placed in care and breached the guarantee of tino rangatiratanga and the principle of active protection in te Tiriti o Waitangi.
d. The Crown failed to protect Māori survivors from losing their whakapapa and connection to whānau, hapū and iwi. This breached the principles of tino rangatiratanga, kāwanatanga (just, fair, and equitable policies and laws), partnership, active protection, and options in te Tiriti o Waitangi.
e. The Crown excluded Māori from decision-making, developing and implementing policies that directly impacted the care of tamariki, rangatahi, and pakeke Māori. This breached the guarantee of tino rangatiratanga and the principles of partnership and active protection in te Tiriti o Waitangi.
f. The Crown’s general exclusion of Māori models of care breached the principles of partnership, active protection, equity, and options in te Tiriti o Waitangi.
g. The Crown stripped Māori of their cultural identity through structural racism. This breached the guarantee of tino rangatiratanga and the principles of kāwanatanga, partnership, active protection, and equity in te Tiriti o Waitangi.
h. The Crown denied the use of te reo Māori through the introduction of policies and practices in care settings and this breached the principle of active protection in te Tiriti o Waitangi.
i. The Crown failed to protect Māori from many forms of abuse and neglect once in care. This breached the principle of active protection in te Tiriti o Waitangi.
j. The Crown failed to collect accurate records of the abuse and neglect experienced by tamariki, rangatahi and pakeke in care. This breached principle of good governance in te Tiriti o Waitangi.
k. The Crown failed to ensure that tamariki, rangatahi and pakeke in care did not experience racism. This breached the principles of equity and equal treatment in te Tiriti o Waitangi.
l. Through failing to appropriately address trauma, caused by abuse and neglect in care the Crown failed to prevent inter-generational impacts on Māori, whānau, hapū, and iwi. This breached the principle of active protection in te Tiriti o Waitangi.
m. The Crown failed to provide appropriate redress for those who suffered abuse and neglect.

Ngā takahi i ngā paerewa atawhai
Breaches of standards of care

n. People in care had rights to standards of care that prevented abuse (ill-treatment) and neglect during the Inquiry period. However:

i. In some settings, particularly disability and mental health, education and faith, the government failed to set adequate or overarching standards of care.
ii. In Deaf, disability and mental health settings, institutions breached the standards they set. Specifically, survivors’ rights to dignity and respect, adequate protection from abuse, neglect and exploitation and proper daily care were consistently breached.
iii. In social welfare settings, staff, social workers, and foster parents breached the standards of care set out in Department of Education Field Officers Manual and its later versions (including the Social Workers Manual).
iv. In transitional and law enforcement settings, NZ Police breached the standards set in their General Instructions. Specifically, by interrogating young people with violence and without the presence of an adult and by holding them in police cells.

o. There were regular and routinely breaches of standards of care with significant impacts for many children, young people and adults in care whose standards were breached.
p. In many institutions, residences, and foster homes, standards were breached every day, due to a lack of resourcing, poor training and confusion about statutory powers and the role of staff or foster parents.
q. Breaches of standards varied in severity. Many were extremely serious. Some breaches of standards were in themselves abuse, while others allowed abuse and neglect to occur.
r. Breaches of standards of care included:

i. neglect and abuse (ill-treatment), including sexual abuse, that was severe, extensive, extreme or pervasive in some institutions
ii. wrongful use of seclusion, solitary confinement and secure care
iii. frequent use of corporal punishment, which at times was extreme, perverse punishment involving weapons and humiliation
iv. frequent breaches of health care standards, at times unlawfully, including:

- lobotomies, sterilisation, forced adoptions, invasive genital examinations, over medicating, and experimental psychiatric treatments without informed consent
- in psychiatric facilities, electric shocks and injections of paraldehyde as punishment, and exposing patients to unreasonable medical risks
- medical neglect and abuse
- medicating people in care for long periods without review
- not providing access to doctors or health specialists for extended periods
- failing to provide a medical certificate on admission to a residence or institution

v. The failure of some social workers to visit State wards in care, a key intervention and rescue point for people experiencing abuse or neglect.
vi. Serious breaches of transitional and law enforcement standards, such as:

- people in care questioned without the presence of a parent, guardian or lawyer
- interrogations using physical violence
- coercion to confess to crimes, even when innocent
- stays in police cells, overnight, sometimes up to weeks.

Ngā take i hua ai te mahi tūkino i ngā pūnaha taurima
Factors which caused or contributed to abuse in care

880. Clause 31(b) of the Terms of Reference requires the Inquiry to make findings on the factors, including systemic factors, which caused or contributed to abuse and neglect.

881. Clause 10.2 of the Terms of Reference refers to factors that include, but are not limited to, the standards that applied in care settings, the vetting, recruitment, training, development and supervisions of staff and carers, the processes available to people in care for raising concerns or complaints, the processes in place to respond to those complaints and how effective they were.

882. In summary, during the Inquiry period the Inquiry finds:

Te hunga i te pū o ngā mahi tūkino
The people at the centre of abuse and neglect

a. Children, young people, and adults in care were diverse, with different care and support needs.
b. Children, young people, and adults in care needed support, protection, and safeguarding when in care.
c. Strong protective factors significantly reduces the risk of abuse and neglect and the likelihood of entry into care.
d. Strong protective factors include connection to whānau, strong self-esteem, supportive trustworthy adults and friends and an understanding of inappropriate behaviour and what to do in difficult situations.
e. The rights guaranteed in te Tiriti o Waitangi are a layer of protection for whānau, hapū, and iwi and their tamariki, rangatahi and pakeke. These rights also reinforce protective factors.
f. Human rights are a layer of protection for children, young people, and adults in care, and their families, whānau, and individual mothers and fathers. Human rights also reinforce protective factors.
g. Many people entering care had weakened protective factors, contributing to the risk they would experience abuse and neglect.
h. Many tamariki, rangatahi and pakeke Māori entered care with few protective factors.
i. Many of the circumstances that made it more likely a person would enter care often became the circumstances for why they were more susceptible to abuse and neglect in care. Those circumstances included:

i. being raised in poverty and experiencing deprivation
ii. being disabled with unmet needs
iii. being Māori and racially targeted
iv. being Pacific and racially targeted
v. being Deaf with unmet needs
vi. experiencing mental distress with unmet needs
vii. being Takatāpui, Rainbow, MVPFAFF+, gender diverse or transgender and targeted 
viii. experiencing significant or multiple adverse childhood events, including:

- experiencing violence, abuse, or neglect in private homes or in other care settings  
- witnessing violence in private homes or in the community or in other care settings 
- having a family member or a peer in a care setting pass away, or attempt or die by suicide 
- aspects of their environment that undermined their sense of safety, stability, and bonding, such as

I. growing up in a private home or in other care settings: 

- with parents, caregivers, or peers experiencing substance use problems 
- with parents, caregivers, or peers experiencing mental distress 
- where there is instability due to parental separation or household members being incarcerated  

II. living in an under-resourced private home or becoming homeless 
III. experiencing unsupported and weakened family and cultural structures 
IV. being in families and communities that were unsupported because their needs had not been adequately assessed or met

ix. having a deferential attitude to people in positions of authority, including faith leaders and medical professionals
x. other circumstances such as age or gender, and
xi. experiencing or being any combination of the above.

j. Abusers were able to misuse their positions of power and control over people in their care to inflict at times extreme and severe abuse and neglect.
k. Abusers were often predatory.
l. Abusers exploited the powerlessness and vulnerability of those they were abusing or neglecting.
m. Abusers often acted with impunity.
n. Some survivors were abused by peers. The risk of peer-on-peer abuse increased when the abuser knew that staff or carers would not hold them to account.
o. Most abusers took steps to conceal their actions. They ensured that survivors’ complaints about abuse and neglect were ignored or suppressed.
p. Many abusers avoided accountability, allowing them to abuse for extended periods and across multiple residences and institutions.
q. Many bystanders (staff, volunteers and carers) failed to stop or report abuse and neglect that they observed or suspected was occurring.

Take hinonga
Institutional factors

r. The following institutional factors contributed to abuse and neglect in care:

i. inadequate, inconsistent and inaccessible standards (including the lack of commitment to human rights and te Tiriti o Waitangi) of care which were routinely breached with little consequence or accountability
ii. individual care needs were not routinely or accurately identified, recorded and met
iii. poor employment policies and poor senior leadership and management practices, including:

- poor or inadequate vetting policies, exacerbated by a lack of access to NZ Police vetting for most settings
- senior leaders and managers sometimes skipping vetting requirements
- senior leaders and managers sometimes knowingly employing abusers with criminal convictions for sexual abuse
- a lack of staff and carer diversity
- under investment in staff and carers
- recruitment of people with service or military backgrounds that contributed to punitive, command and control models of care in some institutions
- poor or inadequate training and development specific to care roles, and on how to recognise the signs of abuse and neglect in care

iv. widely variable, absent, or inaccessible complaints processes that were poorly implemented, including:

- barriers faced by people in care to raise concerns or complaints, including a lack of access to whānau, communities, and advocates
- consistent failures to believe people in care when they reported abuse or neglect, underpinned by societal attitudes like racism, ableism and disablism
- concerns or complaints being treated as an employment issue or as a sin to be forgiven, rather than (in many cases) criminal behaviour
- senior leaders or managers prioritising institutional reputations over the safety of people in care
- senior leaders or managers priorisiting abusers’ reputations and future careers over the safety of people in care, including shifting the abuser to other residences or - institutions and using confidential settlements
- consistent failures to report complaints of abuse and neglect to NZ Police

v. ineffective, ad hoc and insufficient oversight and monitoring, which did little to prevent or respond to known abuse and neglect
vi. consistent accountability failures, that allowed abuse and neglect to continue and gave many abusers a sense of impunity.

s. The State did not take the steps it should have when it saw signs its care system was failing people in care. Those steps should have included:

i. legislation specific to care settings to give effect to the guarantees made to Māori in te Tiriti o Waitangi, particularly tino rangatiratanga
ii. legislation specific to care settings to respect, protect and fulfill the human rights of people in care
iii. a suite of concrete supports or special measures that prioritised the reduction of inequities for families, whānau and communities, supported them to provide care and support at home, and minimised entry into care
iv. steps to minimise and ultimately end institutionalised environments and practices
v. a national framework for safety in care, designed in partnership with Māori and co-designed with people in care, their families, whānau and communities, set out in legislation and made up of:

- a single, overarching national strategy for safety in care that applied to all care settings, seeing them as part of one care system inclusive of faith-based care settings
- a set of easily accessible standards of care that applied to everyone in care, that could be tailored to their needs and culture, regardless of who they were and where they were
- the core requirements of transparent, accessible and responsive complaints processes, including access to advocates
- blanket safety checking requirements that applied to all staff and carers, regardless of their status and role
- consistent mandatory reporting requirements for staff and carers
- consistent accountability for abuse and neglect in care, with swift and effective penalties for non-compliance

vi. best practice training and development standards for staff and carers, and
vii. independent, strategic, well-funded independent oversight and monitoring that looked across all care settings and consistently reported abuse and neglect to NZ Police.

Take ā-whakapono ake
Faith-specific factors

t. The following faith-specific factors contributed to abuse and neglect in care:

i. the authority and impunity of faith-based institutions created opportunities for abuse and neglect to occur and continue
ii. discriminatory attitudes, policies and practices that contributed to abuse and neglect
iii. harmful use of beliefs and practices which created environments that fostered abuse and neglect.

Take ā-pūnaha
Systemic factors

u. The following systemic factors contributed to abuse and neglect in care:

i. people in care, whānau and communities had limited input into State decisions about care
ii. the State’s attempts to deal with institutional discrimination, which impacted who went into care and who experienced abuse and neglect in care, were lack lustre
iii. legislative and policy settings were discriminatory, underpinned by societal attitudes like racism, ableism and disablism, and negative stereotypes of children, young people as delinquents, and negative attitudes towards people living in poverty
iv. the State generally ignored the rights of people in care:

- the State did not give effect to rights guaranteed in te Tiriti o Waitangi, particularly tino rangatiratanga
- the State did not progressively respect, protect and fulfil the human rights of people in care and their whānau

v. the State lacked diversity and lived experience of care in its leadership
vi. the State did not ensure people in care were safeguarded from abuse or neglect, or had effective oversight and monitoring
vii. there was a lack of State accountability for abuse and neglect, particularly those with statutory responsibilities to people in care
viii. the State did not ensure there was a comprehensive regulatory care framework that was enforced and properly invested in and resourced
ix. the State failed to respond to signs of systemic abuse and neglect, taking no steps to understand if its system of care was failing
x. the State’s structure clouded its response to signs of system failure.

v. The State did not take the steps it should have when it saw signs its care system was failing people in care. Those steps should have included:

i. legislation specific to care settings to give effect to the guarantees made to Māori in te Tiriti o Waitangi, particularly tino rangatiratanga
ii. legislation specific to care settings to respect, protect and fulfill the human rights of people in care
iii. a suite of concrete supports or special measures that prioritised the reduction of inequities for families, whānau and communities, supported them to provide care and support at home, and minimised entry into care
iv. steps to minimise and ultimately end institutionalised environments and practices
v. a national framework for safety in care, designed in partnership with Māori and co-designed with people in care, their families, whānau and communities, set out in legislation and made up of:

- a single, overarching national strategy for safety in care that applied to all care settings, seeing them as part of one care system inclusive of faith-based care settings
- a set of easily accessible standards of care that applied to everyone in care, that could be tailored to their needs and culture, regardless of who they were and where they were,
- the core requirements of transparent, accessible and responsive complaints processes, including access to advocates
- blanket safety checking requirements that applied to all staff and carers, regardless of their status and role
- consistent mandatory reporting requirements for staff and carers
- consistent accountability for abuse and neglect in care, with swift and effective penalties for non-compliance.

vi. best practice training and development standards for staff and carers, and
vii. independent, strategic, well-funded independent oversight and monitoring that looked across all care settings and consistently reported abuse and neglect to NZ Police.

Take ā-iwi
Societal factors

w. The following societal factors contributed to abuse and neglect in care:

i. discriminatory societal attitudes like racism, ableism, disablism, sexism, homophobia, transphobia and negative stereotypes, directly contributed to survivors entering care and suffering abuse and neglect in care, with Māori and Pacific Peoples, Deaf, disabled people, people experiencing mental distress, and Takatāpui, Rainbow and MVPFAFF+ people being disproportionately affected.
ii. negative views about people living in poverty and welfare dependency
iii. belief systems that upheld reverence and trust in faith-based institutions and members of faith
iv. negative views towards children and young people, as delinquents, naughty and not to be believed

v. society condoned and tolerated institutionalisation of people for decades.

Whakatau hē
Findings of fault

883. Clause 33 of the Terms of Reference allows the Inquiry to make findings of fault. In summary, during the Inquiry period the Inquiry finds:

Te Kāwanatanga
The State

Ngā takinga toko i te ora
Social welfare settings

a. Relevant Ministers, the Superintendent of the Child Welfare Division, Department of Education and then subsequently the Director-General and Chief Executive of the Department of Social Welfare and its successors were at fault for:

i. failing to address structural racism in the care system
ii. the adverse effects of structural racism on tamariki, rangatahi, and pakeke Māori in care, their whānau, hapū, and iwi, and has an ongoing detrimental impact on the relationship between Māori and the Crown
iii. failing to address structural ableism and disablism in the care system
iv. not consistently supporting whānau to prevent people from entering care
v. insufficient emphasis on whānau-based alternatives to State care
vi. often ignoring Māori perspectives and solutions
vii. failing to fully meet the needs of all of those in care
viii. failing to ensure people in care were kept safe from harm
ix. failing to ensure caregivers in social welfare settings were properly vetted, trained, supported, and monitored
x. inadequate policies, processes and practices to always detect and facilitate the reporting of abuse and neglect
xi. the ongoing impacts of abuse and neglect for survivors and their whānau
xii. failing to consistently believe or follow up reports of harm in social welfare settings
xiii. inadequate protection and preservation of the records and case files of all people in care, which impacts survivors today.

Ngā takinga ā-Turi, whaikaha, hauora hinengaro
Deaf, disability and mental health settings

b. Relevant Ministers, Directors-General of Health and Directors of Mental Health were at fault for:

i. the policy of institutionalisation from the 1950s to 1970s which resulted in Deaf, disabled people, and people experiencing mental distress being placed in settings where many experienced abuse and neglect. This was despite advice from the World Health Organisation that institutionalisation was opposite to best practice at the time, which was reiterated in the 1959 Burns Report by the Aotearoa New Zealand branch of the British Medical Association
ii. institutional and societal ableism in legislation, policy and systems that contributed to the abuse of Deaf, disabled people and people experiencing mental distress in health and disability institutions
iii. institutional racism in legislation, policy and systems that contributed to the abuse of Māori and Pacific Peoples in health and disability settings
iv. ableist health and disability care settings that did not always meet the needs of Deaf, disabled people and people experiencing mental distress
v. ignoring the perspectives and solutions of disabled people and their whānau
vi. Māori, Pacific Peoples, Deaf, disabled people, and people experiencing mental distress being particularly negatively impacted, through being overrepresented in care, or their distinct needs not being met in care, including because of abuse suffered
vii. Deaf, disabled people and people experiencing mental distress not always being supported to make decisions about their own lives especially adults
viii. legislative and policy settings that did not ensure sufficient emphasis on alternatives to placing Deaf, disabled people and people experiencing mental distress into institutionalised care, like exploring family or community-based care options
ix. legislative and policy settings that did not always provide adequate support and resourcing to whānau, including disability support and resourcing
x. failing to fully meet the needs of all of those in care
xi. not consistently and meaningfully ensuring the cultural needs of all Māori in care were met, including culturally appropriate health care options, causing disconnection from their culture, identity, language and communities, with ongoing impacts for them, and their whānau, hapū and iwi
xii. not consistently and meaningfully ensuring the cultural needs of all Pacific Peoples in care were met, including culturally appropriate health care options, causing disconnection from their culture, identity, language and communities, with ongoing impacts for them, and kainga and wider communities
xiii. failing to ensure people in care were kept safe from harm when they should have been
xiv. inadequate policies, processes and practices to safeguard people in care
xv. inadequate policies, processes and practices, including reporting, to detect abuse and neglect
xvi. people in care experiencing abuse and neglect, which has had ongoing impacts for survivors and their whānau
xvii. inappropriate use of seclusion and restraint in psychopaedic and psychiatric settings and inappropriate use of medication, aversion practices, and shock treatment, and acts that met the Solicitor-General’s definition of torture
xviii. failing to maintain accurate records, including not recording ethnicity, Deaf, disability or mental distress or impairment, compounded by the loss of records, has resulted in the true number of those in care will never be known.

Ngā takinga mātauranga
Education settings

c. Relevant Ministers, Secretaries and Chief Executives of Education were at fault for:

i. failing to provide education fit for different groups, including Blind, Deaf, and disabled children and young people
ii. failing to support New Zealand Sign Language and the language and cultural needs of Deaf people
iii. failing to identify and support the needs of neurodivergent people
iv. ignoring Deaf and disabled peoples’ and communities’ perspectives and solutions
v. failing to actively protect te reo and encourage its use by Māori, which was in breach of te Tiriti o Waitangi, and has had an ongoing detrimental effect for Māori
vi. not sufficiently valuing Māori culture
vii. failing to respond to the identity, language, and culture of Māori which has been harmful, and contributed to poor education outcomes
viii. having consistently lower expectations of tamariki and rangatahi Māori
ix. having less oversight of private schools than State or State-integrated schools, which may have increased opportunities for abusers
x. failing to keep children safe, during the school day and in overnight/boarding care
xi. failing to keep children in some schools and boarding facilities connected with whānau.

Ngā takinga whakatika, mauhere ā-ture
Transitional and law enforcement settings

d. Successive Commissioners of NZ Police were at fault for:

i. negative Māori experiences with policing
ii. failing to recognise the importance of te Tiriti o Waitangi until the mid-1970s
iii. failing to understand the role of NZ Police in the disproportionate representation of Māori in the criminal justice system
iv. NZ Police responses to Māori over-representation in the criminal justice system that fell short of a full commitment to the principles of te Tiriti o Waitangi
vi. failing to value tikanga Māori as part of policing practice, for most of the Inquiry period
vii. Pacific Peoples’ negative experiences with policing
viii. failing to understand whether ableism within NZ Police contributed to disproportionate representation of disabled people in the criminal justice system
ix. inadequate policies, processes, and procedures to support Deaf, disabled people and people experiencing mental distress to engage with NZ Police
x. during the 1950s to 1970s, a singular focus on enforcement
xi. during the 1950s to 1989, not consistently considering alternatives to criminal proceedings for children and young people
xii. Before 1989, not being inclusive whānau in the decision-making impacting the person in their care
xiii. failing to consistently follow General Instructions and related policies regarding children, young people and adults in their care, such as questioning people under the age of 14 without the presence of any parent, guardian or lawyer
xiv. the use of police cells to detain children and young people (due to lack of alternatives), which was, and remains, unsuitable for children and young people, particularly those in care and protection
xv. the abuse and neglect people experienced while in transitional and law enforcement settings, including physical abuse
xvi. failing to understand or investigate the nature and extent of police abuse of people in transitional and law enforcement care settings
xvii. General Instructions that limited who could access vetting during the Inquiry period, particularly between 1977 and 1991
xviii. lacking a universal policy on how to respond to allegations of abuse and neglect in care
xix. before 1995, lacking a dedicated policy relating to investigation of sexual abuse and serious physical abuse of children
xx. lacking awareness of the risk of sexual offending by people in positions of authority
xxi. negative bias against victims of abuse and neglect who were not believed or considered reliable or credible, for example at times assuming that Deaf, disabled people, and people experiencing mental distress may not be credible witnesses, or assuming promiscuity of a young survivor when investigating allegations of sexual abuse in care
xxii. failures to investigate abuse and neglect against children, young people and adults in care
xxiii. lacking statistical data on allegations of abuse and neglect in care
xxiv. the racism and discrimination exhibited by some leaders within NZ Police
xxv. failing to collect data on the diversity of the NZ Police workforce, specifically ethnicity and the number of Deaf or disabled police.

Ngā takinga ā-pūnaha taurima katoa
Whole of care system settings

e. Successive governments were at fault for:

i. institutional, structural racism and ableism in legislation, policy and systems that contributed to the disproportionate representation, and discriminatory treatment of Māori, Pacific Peoples, Deaf, disabled people, people experiencing mental distress, and Takatāpui, Rainbow and MVPFAFF+ people in care
ii. the alienation of tamariki, rangatahi, and pakeke Māori from their whānau, hapū, and iwi, and their culture, identity, language, and the ongoing impacts of that alienation
iii. the alienation of Pacific Peoples from their kainga, culture, identity, language, and the ongoing impacts of that alienation
iv. the alienation of Deaf people from their whānau and communities, and their culture, identity, language, and the ongoing impacts of that alienation
v. the abuse and neglect people experienced while in care
vi. failing to ensure that people in care were safe from abuse and neglect
vii. failing to consistently stop abuse and neglect in care when it was disclosed or reported
viii. record-keeping issues, including gaps and loss of records, which mean the true number and make up of children, young people and adults in care is unlikely to ever be known.

f. Successive State or Public Service Commissioners (responsible for the integrity and conduct of public servants, and the appointment and performance of chief executives) were at fault for failing to hold chief executives to account for:

i. preventing abuse and neglect in care
ii. not adequately identifying and investigating abuse and neglect in care
iii. appropriately responding to complaints of abuse and neglect in care by both protecting people in care and holding abusers to account
iv. providing holistic redress for survivors of abuse and neglect in care
v. addressing the role the public service played in being responsible for the abuse and neglect people experienced and the ongoing impacts of such abuse and neglect while in State care
vi. addressing the public servants not following the standards of successive codes of conduct
vii. the lack of a cohesive public service to provide joined-up, comprehensive and coherent safeguarding of children, young people and adults in care
viii. there being no appropriate public service framework for:

• • • • • • • • • • • • ensuring the care workforce were diverse and reflected the makeup of society
                      • ensuring workplaces were inclusive of all groups in society
                      • focusing on developing and maintaining public service capability to engage with Māori and understand Māori perspectives.

Ngā whakapono
Faiths

g. The Catholic Church was at fault for:

i. the harm that has taken place in some Catholic educational institutions. That harm includes:

- serious sexual harm and inappropriate physical punishment
- inadequate steps taken in response to complaints of abuse and neglect
- putting students at risk of harm by appointing abusers to the school without effective methods in place for protecting students
- placing a heavy reliance on the opinions of psychiatrists in determining the ability of an abuser to rehabilitate and continue working in certain areas or in ministry, - - which resulted in abusers being transferred to other areas of ministry where re-offending occurred

ii. being slow to act when sexual abuse was occurring
iii. children being harmed in Catholic institutions where they should have been cared for and safe
iv. harm caused to children because of mistakes made by the Church which could have and should have been avoided
v. not doing more to prevent the pain and suffering of all those who should have been kept safe in the church’s care
vi. the following factors which caused abuse to occur or prevented its disclosure:

- prioritising forgiveness over safeguarding and accountability for those who perpetrated the abuse and the leadership at the time with knowledge of the abuse
- creating a power imbalance between religious/clergy and their parishioners
- lack of resources of, and investment in, those with the care of children, young people and adults (when they should not have been in those positions)
- lack of training for those in care of children, young people and adults
- care for the reputation of the church.

h. The Anglican Church was at fault for:

i. the failures of those within the Church who were meant to protect and care for people in their care
ii. abuse and neglect in the care of the Church
iii. abuse and neglect that included sexual abuse, physical abuse, verbal abuse and emotional abuse and neglect
iv. perpetuating societal attitudes in its institutions, like corporal punishment, normalised bullying in schools, and suppressing Māori and Pacific Peoples’ culture
v. failing to implement institutional monitoring, leaving the responsibility of management up to individual leaders
vi. failing to implement an overarching Church policy or process to guide the handling of complaints of abuse, including record-keeping
vii. leaving allegations and complaints of abuse to be handled by those who knew the alleged abusers well, with some unwilling to accept a fellow clergy member could be an abuser
viii. abuse that was ignored or covered up within the Church, which failed to protect people in care and failed to hold abusers to account
ix. perpetrators of abuse who were protected by the sanctity of their role within Anglican institutions
x. failing to believe the survivor when they first came forward, instead survivors were often deemed untrustworthy or deceitful
xi. survivors having to live with the consequences of the trauma they suffered for decades
xii. the families of survivors having to carry the long-term consequences of abuse and neglect
xiii. the role of patriarchy within the Church in failing to listen and respond to issues of abuse and neglect
xiv. being too trusting of individuals within the Church, which contributed to the Church’s failure to address its mistakes sooner.

i. The Methodist Church was at fault for:

i. failing in its duty to ensure the protection and wellbeing of those in its care
ii. the pain and suffering of all those who were abused in the Church’s care, including:

- those who suffered abuse while at Wesley College in Pukekohe
- those who suffered abuse in former children’s homes, in Ōtautahi Christchurch, Whakaoriori Masterton, and Tāmaki Makaurau Auckland
- those who suffered abuse by a Minister, foster parents or in other Methodist Church parish settings
- those who suffered abuse, which remains unreported

iii. Abuse and neglect, including sexual, physical, emotional and psychological abuse and neglect
iv. insufficient monitoring, oversight and safeguarding of those in their care, which enabled abuse to occur
v. failing to implement protection policies and procedures across all its Church-related entities
vi. failing to implement mandatory NZ Police vetting
vii. failing to consistently implement key changes on an “all of Church” approach to ensure those providing care were adequately trained and resourced
viii. failings in addressing complaints, including not always accepting and acting appropriately on reports of abuse and complaints.
ix. responding to complaints with a traditional legal approach that included:

- requiring survivors to report their abuse to NZ Police before conducting its own inquiries
- declining to progress claims in a way that meant survivors had to pursue legal claims in the courts
- failing to recognise it had a duty to take action to discipline a member of the Church, particularly a Minister

x. failing to recognise the Church’s role to deliver a restorative response to reports or complaints of abuse
xi. the additional harm caused to survivors when the Church initially refused to believe them, sought to contest their concerns, or refer the complaint elsewhere, and failing to recognise the Church needed to address their complaint
xii. the trauma experienced as a result of abuse, which has had long term impacts on the lives of survivors, their whānau and loved ones
xiii. failing to have record keeping policies relating to reports or complaints of abuse and neglect.

j. From Gloriavale's inception in 1969 through to the end of the Inquiry period, the Overseeing Shepherd and senior leadership of the Gloriavale Christian Community were at fault for:

i. allowing physical and sexual abuse to happen within the community
ii. failing to address intergenerational sexual abuse within the community which perpetrated a cycle of harm
iii. failing to prevent and protect survivors within the community against abuse
iv. responding to allegations of abuse by seeking to create repentance from the offender and forgiveness from the victim
v. failing to recognise the harm of abuse on survivors
vi. failing to deal with perpetrators of abuse appropriately, allowing them to continue living in the community and allowing abuse to continue within the congregation as a result
vii. failing to recognise the scale and extent of abuse in the community
viii. dealing with complaints of abuse themselves and not engaging any other authorities or professionals, including NZ Police or Oranga Tamariki and its predecessors
ix. the role the community’s Doctrines had in creating a culture that allowed abuse to occur.

k. The Presbyterian Church were at fault for:

i. its reluctance to confront abuse
ii. failing to remove people who posed risks to children, young people and adults in their care from unsupervised participation in the Church
iii. its reluctance to make binding rules
iv. failing to recognise ministers, elders or leaders as people who could cause harm
v. its dynamic of protecting the congregation from outside interference, creating a risk of abuse and neglect
vi. discounting complaints of abuse
vii. failing to report complaints of abuse to proper Church authorities or to NZ Police, allowing perpetrators to continue abusing
viii. not supporting survivors to make complaints, making them feel isolated, discouraging them from taking complaints further and not believing them
ix. removing perpetrators from one area but allowing them to continue in other areas without considering the risks
x. deliberately attempting to suppress reports of abuse at times
xi. failing to apply its policy of zero tolerance of abuse of people in the case of the Church consistently and thoroughly
xii. failing to consistently uphold its Code of Ethics in relation to pastoral care adopted in 1995
xiii. failing to consistently report breaches of its Code of Ethics.

l. Additionally, Presbyterian Support Services Central was at fault for:

i. failing to properly record the ethnicities of Māori and Pacific children in the care of Berhampore Home in Te Whanganui-ā-Tara Wellington.
ii. failing to prioritise any understanding of how to better deliver care to disabled people.

m. The Salvation Army was at fault for:

i. lack of understanding of the abuse and neglect of children, young people and adults in their care, and its effects on survivors, sometimes lasting for a lifetime
ii. wide-ranging abuse and neglect in their care, which included sexual, physical and psychological abuse and neglect and mistreatment
iii. abuse and neglect carried out by staff and officers of the Salvation Army, by other residents or visitors to homes, and foster parents and caregivers
iv. abuse and neglect in their homes for unwed mothers, including Bethany homes, including pressure to have their children adopted, while being denied relevant information, medical and emotional help and support
v. abuse and neglect in children’s homes in Whakaoriori Masterton, Temuka, Tāmaki Makaurau Auckland, Putaruru, Eltham in Taranaki, Te Whanganui-ā-Tara Wellington, and Kirikiriroa Hamilton
vi. serious neglect in some children’s homes and homes for unwed mothers, including inadequate nutrition, hygiene and healthcare
vii. abuse that included racism, ableism, and discrimination based on gender and sexuality.

Ngā roopu hunga mātanga
Professional bodies

n. The New Zealand Medical Association and Medical Council of New Zealand were at fault for:

i. actions that the New Zealand Medical Association and Medical Council of New Zealand should have taken, but did not, to protect the public
ii. decisions in relation to complaints of abuse, that the Medical Council of New Zealand cannot now explain due to the incompleteness of records
iii. the New Zealand Medical Association prioritising fairness to doctors (including psychiatrists) over the safety and wellbeing of patients when investigating complaints
iv. accepting much of Dr Selwyn Leeks’ response to allegations without question when investigating a complaint against Dr Leeks in 1977.

o. The Nursing Council of New Zealand and its predecessors were at fault for not taking appropriate care of survivors, and their whānau, involved in its processes, resulting in unacceptable instances of harm. For some survivors, those processes have had a significant and ongoing impact.

p. The Teaching Council of Aotearoa New Zealand and its predecessors were at fault for not taking appropriate care of survivors, and their whānau, involved in its processes, resulting in unacceptable instances of harm. For some survivors, those processes have had a significant and ongoing impact.

Ngā akonga i kitea he mea panoni
Lessons identified and changes made

884. Clause 31(e) of the Terms of Reference requires the Inquiry to make findings on the lessons learned, and what changes were made to prevent and respond to abuse. The Inquiry finds:

Te hunga i te pū o ngā mahi tūkino
The people at the centre of abuse and neglect

a. The State made discrete changes to safeguard against abuse and neglect and increase protective factors for people in care during the Inquiry period, generally from the late 1980s onwards.
b. Some faith-based institutions began to introduce some safeguarding and protective factors from the late 1980s onward.
c. There were discrete changes to support the role of staff and carers in detecting and responding to abuse, mainly relating to training and voluntary reporting from the late 1980s onwards.

Ngā kawenga atawhai a ngā hinonga me ngā kāinga tamariki atawhai
The institutions and foster homes responsible for care

d. The State legislated for standards of care in some settings from the mid to late 1980s onwards.
e. The State made changes to regulate some staff in some care settings, such as teachers, and progressively developed policies in State settings on recruitment, vetting, training, development and supervision from the 1970 onwards.
f. The State introduced detailed regulations on complaints processes for people in social welfare residences and institutions in 1986 and people subject to a compulsory mental health assessment or treatment order in 1996.

Ngā kawenga atawhai ā-whakapono
The faiths responsible for care

g. Faith-based care settings either did not make changes or were slow to make changes to prevent and respond to abuse during the Inquiry period.

Ngā kawenga atawhai a te Kāwanatanga
The State’s responsibility for care

h. The State was slow to learn and act on critical lessons identified about abuse and neglect in care and many changes were not made until the 1980s onwards.
i. The State made many changes toward the end of the Inquiry period, including the creation of new legislation, policies and standards as new lessons were being identified and calls for change were being made.
j. The State made changes to prevent and respond to abuse and neglect with good intentions but these were not always realised due to implementation failures.
k. The State learned lessons about the impact of institutionalisation and segregation on Deaf, disabled people and people experiencing mental distress but was slow to take action in response.
l. The State learned lessons about the overrepresentation of Māori across all care settings, but changes were generally not made until the late 1980s to try to address this.
m. Changes made throughout the Inquiry period to prevent and respond to abuse and neglect were inconsistent across care settings.
n. Changes made were substantially smaller than the scale of abuse and neglect in care.
o. Many discrete policy changes were made to respond to abuse and neglect in Social Welfare settings.
p. Changes by the State were slow and few to prevent and respond to abuse and neglect in Deaf, disability and mental health settings.
q. The State did not make changes to prevent or respond to abuse and neglect in many faith-based settings during the Inquiry period.
r. Societal attitudes changed over the Inquiry period.
s. The State made some changes to try and eliminate discriminatory institutional policies and practices.