208.Many staff and carers in State and faith-based institutions genuinely approached their position to do the best they could for those in their care. While many did, poor employment policies combined with poor senior leadership and management practices could undermine or make it harder for individual staff and carers to safeguard people in care.[240]

209.Generally, employment policies and practices were left to each setting to decide what was needed from 1950 through to the late 1980s. Some departments would set broad, process-based requirements through service contracts.[241] From the late 1980s, different settings had different legal obligations. For example, from 1989 the Director-General of Social Welfare had a legal duty to ensure that people delivering social services received adequate training and complied with appropriate standards.[242]

210.This chapter focuses on vetting, recruitment, training and development, and supervision of staff and carers. It relates to clauses 31(b) and 10.2(a) of the Terms of Reference.

Ngā wherawheranga kaimahi i te wā o te Pakirehua
Vetting during the Inquiry period

Kāhore he ture tohe i te wherawheranga kaimahi, kaiatawhai hoki
No statutory requirement to vet staff and carers

211.Throughout the Inquiry period, there was no statutory requirement to vet prospective staff or carers, paid or voluntary, in any State or faith-based care setting. In the absence of legal direction, settings followed the State Services Commission’s policies, designed their own, or had no policies in place. From the 1980s onwards, vetting requirements were part of service contract requirements in social welfare and Deaf, disability and mental health settings.

212. NZ Police had no statutory framework for responding to vetting requests. Up until 1978, NZ Police had a practice of only allowing limited enquiries of someone’s background and only in relation to certain categories of requests.[243] These categories included examples where NZ Police considered that doing so was in the public interest or where they deemed the organisation could not do it themselves.

213. In 1978, two years after the creation of a centralised and searchable database of criminal convictions, NZ Police developed internal guidelines for responding to vetting requests.[244] Those guidelines were that vetting requests would only be carried out for listed organisations, initially limited to prospective foster and adoptive parents in social welfare settings (the only listed organisations relevant to this Inquiry).[245]

214. From 1950 to the late 1970s, with no formal vetting arrangements in place, most care settings who wanted to vet applicants were generally reliant on the honesty of applicants to declare any prior convictions on job applications, with no formal means to verify their responses.[246]

Ngā kaupapa wherawhera i roto i ngā takinga whaikaha, hauora hinengaro
Vetting policies in disability and mental health settings

215.In disability and mental health settings, there were no mandatory vetting requirements or policies. At times there was a deference to membership of professional bodies like the New Zealand Medical Council, the regulatory body for doctors.

216. The Medical Council could not register people who had been convicted of any offence punishable by imprisonment of two years or more or who were “otherwise not of good fame or character”.[247]

217.The Medical Practitioners Act 1995 tightened restrictions on registration. Doctors who had been convicted of any offence punishable by imprisonment for a term of three months or longer had to satisfy the Medical Council that the offence would “not reflect adversely on his or her fitness to practice medicine”.[248] The Medical Council could also decline registration if an individual was “not fit to practice medicine by reason of any mental or physical condition”,[249] if they had been the subject of professional disciplinary proceedings,[250] or were otherwise “not fit to practice medicine”.[251]

218.However, as the Medical Council acknowledged at the Inquiry’s Lake Alice Child and Adolescent Unit Hearing in June 2021, it did not always act to ensure that people in care were safe from doctors who should not have been practicing.[252] They also acknowledged that due to the length of time that had passed and the incompleteness of records available to the current Council, it was not able to provide reasons for decisions that were made in the past in relation to complaints of abuse or in relation to Dr Selwyn Leeks.[253] The Medical Council told the Inquiry that if Dr Leeks’ conduct occurred today and it was notified of his conduct, “there is no way Dr Leeks would be practicing”.[254]

219. The Nursing Council of New Zealand decided who could become a registered nurse. Throughout most of the Inquiry period the only restrictions outlined in the governing legislation were that the nurse had to be a certain age and “of good character and reputation”.[255]

Ngā kaupapa wherawhera i roto i ngā takinga toko i te ora
Vetting policies in social welfare settings

220. In social welfare settings, vetting of foster parents was discretionary between 1950 and 1970. Between 1970 and 1980, vetting of foster parents was required as part of best practice policy.[256]

221. It is unclear when vetting requirements for social workers and staff at social welfare residences and institutions became part of formal recruitment policy.[257]

Ngā kaupapa wherawhera i roto i ngā takinga mātauranga
Vetting policies in education settings

222. In education settings, including special schools for Deaf students, there was no mandatory vetting requirement or policies for teachers or education staff and carers during the Inquiry period.[258] Between 1950 and 1989, regional education boards were responsible for their own policies for vetting. From 1989, this responsibility shifted to boards of trustees. Several schools did not vet new staff.[259]

223. Up until 1989, the Department of Education registered teachers, with a focus on skills and good character. There was no requirement to vet teachers before they worked in education settings. From 1989, the Teaching Council took over this role.

224. There was no requirement to vet individuals who wanted to register and open a private school.[260] Anyone could open a private school so long as the school met the criteria of “efficiency”. Even if vetting was carried out and it revealed criminal convictions, it was not a ground to decline registration of the school.[261]

Ngā kaupapa wherawhera i roto i ngā takinga pūnaha taurima ā-whakapono
Vetting policies in faith-based care settings

225. Across all faith-based care settings, the State did not legislate for any mandatory vetting requirements or policies throughout the Inquiry period. There were varying approaches to vetting across faiths, but most were inadequate and ineffective.

226. Catholic institutions lacked adequate procedures for the selection and vetting of potential clergy, religious (members of religious orders) and lay staff. This led to the appointment in some cases of inappropriate and unqualified staff, which increased the risk of abuse.

227. The Methodist Church did not have mandatory vetting requirements or policies during the Inquiry period. Vetting processes were managed by individual childrens’ homes. The Methodist Church explained that their vetting processes were “at best ad-hoc and depended on knowledge in the public domain and disclosures by the person concerned”.[262]

228. The Anglican Church did not have consistent, mandatory vetting requirements or policies.

229. The Inquiry heard that elder appointments in the Plymouth Brethren Christian Church were based on their standing within the community and there were no formal vetting processes for those appointed to leadership roles.[263]

230. Presbyterian Support Otago acknowledged that “individuals who were married, part of a church or involved with community objectives were believed to be upstanding and suitable to be involved in the care of children”, and did not need vetting, which was “naive”.[264]

231. In the Salvation Army, staff shortages meant that little was done at times to screen the suitability of lay staff. However, Salvation Army officers were subject to more reference checks and training.[265]

232. Gloriavale told the Inquiry that their leadership were not NZ Police vetted, except for those who work in the school or early childhood centres.[266]

Kīhai i āta wherahia te tū wātea o te hunga i ngā pūnaha taurima i te kaitūkino
Absence of vetting exposed people in care to abusers

233. Across all settings, absent, inadequate or poor implementation of vetting policies increased the risk of people in care being exposed to abusers.[267] At times, this risk resulted in serious sexual abuse.

Nā te kore o te kaupapa wherawhera i āhei ai te whai mahi a te kaitōkai tamariki
Absent vetting led to serious child sexual abusers being employed

234. There were several examples of social welfare residences and institutions where staff who had histories of child sexual abuse allegations and convictions were unknowingly employed through absent vetting.[268] Michael Ansell, who went on to sexually abuse multiple boys while employed at Hokio Beach School near Taitoko Levin, was hired in 1973 despite being convicted in 1969 for sexually abusing a 14 year old boy.[269] The Assistant Principal of Hokio Beach School from that time later explained:

“given the systems in place at the time, in particular the absence of any comprehensive vetting system for criminal activity, [Hokio Beach School Manager] Keith North simply had no way of knowing.”[270]

235. The same problems with vetting were happening more than a decade later. For example, in 1986, the Department of Social Welfare said that they had no way of knowing that a staff member was a convicted sex offender when they employed him. He had been convicted of sexually assaulting a young person in 1964 and was employed by the Department in 1983, where he worked at two Auckland boys’ homes until he was once again arrested and convicted of sexually assaulting a different boy. The Department said he had indicated in his job application that he had no convictions, but they had no access to NZ Police’s vetting system to verify his response.[271]

236. The systemic failures of employing a carer with 24 allegations of abuse was noted as “we didn’t do our best work at that time”[272] by the Ministry of Social Development’s chief executive Debbie Power at the Inquiry’s State Institutional Response Hearing.

Kīhai i wherawheratia ētahi tāngata nā te whakapono he hunga tōtika rātou
People were sometimes not vetted because they were assumed to be trustworthy

237. In some cases, vetting policies or practices were not followed because of an assumed high trust in the applicant.[273]

238. At the Inquiry’s Faith-based Institutional Response Hearing and in response to the example of Methodist Minister Reverend Albert Grundy, who repeatedly abused a survivor in his care, General Secretary of the Methodist Church Reverend Tara Tautari acknowledged that this was:

“a prime example of where we took it for granted that this person was good because the person was known. And so therefore due diligence is put to the side because of so-called personal knowledge and also a deference to their standing and status.”[274]

Tērā ētahi kaitaki, kaiwhakahaere matua i āta tohi kaimahi me te ārai i aua kaitōkai
Senior leaders and managers sometimes knowingly employed and protected sexual abusers

239. In both State and faith-based care settings, some senior leaders or managers appointed an abuser into a position despite knowing they had former criminal convictions for child sexual abuse.

240. Standards and Monitoring Services Chief Executive Officer Mark Benjamin told the Inquiry how a staff member at a Christchurch disability group home was convicted of sexually abusing at least one of the residents.[275] Several years later, Standards and Monitoring Services discovered the same staff member had been re-employed at the same home.[276] When questioned about their decision, Mr Benjamin recalled them saying that they felt the perpetrator has “paid [his] price and deserved a second chance”.[277]

241. The Department of Social Welfare also re-employed staff who had previous allegations of abuse against them. In the 1980s, Edward Anand was reported by a fellow staff member for sexually abusing girls while working at Dunedin Girls’ Home in Ōtepoti Dunedin. He denied the allegations but admitted to engaging in group massage with the girls, and to hugging and kissing them but believed this was no different to how other staff engaged with the girls.[278] He resigned before a complaint was referred to NZ Police. The Head of the home wrote to the Director-General of Social Welfare advising that Mr Anand “must never be allowed to work in the State Services again”.[279] He was later hired at Epuni Boys’ Home in Te Awa Kairangi ki Tai Lower Hutt, despite Mr Anand disclosing that he had previously worked at Dunedin Girls’ Home and his staff card reading “not suitable for re-employment”.[280] Edward Anand was later convicted of sexually abusing eight girls at the home, aged between 10 and 15 years old.[281]

242. In 1979 Father Alan Woodcock was convicted of indecently assaulting a 17 year old male. In 1982, Provincial Father Bliss appointed him to a teaching position at St Patrick’s College (Catholic) in Te Awa Kairangi ki Uta Upper Hutt, knowing he had a criminal conviction.[282] Within a year, there was a report of abuse against Father Alan Woodcock.[283] He was later convicted again for serious sexual offending against 11 boys.

243. The Salvation Army offered Raymond Vince a position in 1997 despite receiving reports of sexual abuse in 1992. On hearing the Salvation Army had offered him this position, some members of his family objected and threatened the Salvation Army that they would go to NZ Police “on the grounds they felt others could be unsafe”.[284]

244. Raymond Vince resigned and went on to work as a drug and alcohol counsellor. In 2008, he was jailed for nine charges of indecent assault of girls under the age of 12 years old, and one charge of rape of a girl between the age of 12 and 16 years old. These charges related to his time at the Salvation Army’s Bramwell Booth Home in Temuka between 1977 and 1981.

245. Hopeful Christian was able to return to Gloriavale when he was released on parole after he served a prison sentence for indecently assaulting a young girl in the community. NZ European survivor Rosanna Overcomer, survivor and Gloriavale Leaver’s Trust representative, told the Inquiry that:

“he was allowed back into our community, the community where I, a child, lived. The people that should have cared for the children and vulnerable allowed a sex offender not only into a close-knit community with inadequate living quarters but back into the senior position of leadership as the Shepherd of the church.”[285]

Nā te ngoikore me te paku o ngā rawa tautoko i hua ai te mahi tūkino
Inadequate recruitment and under resourcing contributed to abuse and neglect

Kāhore i hāngai rawa ngā kaimahi me ngā kaiatawhai ki te hunga i ngā pūnaha taurima
Staff and carers were not representative of the people in care

246. An absence or lack of respect for staff and carer diversity increased the risk of abuse or neglect.[286] Some staff or carers abused or neglected those in their care who were different to them, linked to underlying societal attitudes like racism or ableism. Other staff or carers, who themselves had been victimised, intimidated or bullied for their diversity by their colleagues, found it harder to raise or report concerns about abuse or neglect. It also impacted whether a person in care felt they could safely disclose abuse. Māori survivor Reverend Dinah Lambert (Ngā Rauru Kītahi, Ngāti Porou, Ngāti Kahungunu), who was at Abbotsford Home (Anglican) in Waipawa, Te Matau-a-Māui Hawkes Bay in the 1960s, told the Inquiry how she would approach disclosing her abuse now:

“if I was that child, I would just run to the nearest Māori family. That’s who I would go to because I’d go to my own … because I would feel more safe in doing that as a child then.”[287]

247. Māori survivors described a lack of Māori staff at care institutions despite being over-represented in these settings.[288] Reviews of social welfare homes in the 1970s and 1980s found that Māori culture and values were absent and sometimes resisted by non-Māori staff.[289] This was despite Māori making up the majority of tamariki and rangatahi in these settings.[290] Tā Kim Workman said when he visited Kohitere Boys’ Training Centre in Taitoko Levin as a Youth Aid Officer in the early 1970s, there were very few Māori staff and a total absence of any cultural input into the lives of young Māori people.[291] This lack of representation was in part a result of Pākehā focused recruitment processes.[292]

248. Most staff and carers in all settings were Pākehā, while most people in care were not.[293] This stark contrast was recognised as early as the 1970s.[294] The 1979 report of the Auckland Committee on Racism and Discrimination into children’s residential homes concluded that addressing the monocultural and “mono-racial” staffing “would be the first measure necessary to help eradicate the inherent racism within the homes”.[295]

249. A 1985 report by the Department of Social Welfare reported that, in residences in Tāmaki Makaurau Auckland:

a. 62 percent of residents were Māori compared to 22 percent of staff
b. 16 percent of residents were Pacific Peoples compared to 5 percent of staff
c. 22 percent of residents were Pākehā compared to 71 percent of staff.[296]

250. A 1988 study into the experiences of foster children and their foster families found that over 75 percent of foster parents were Pākehā at a time when 45 percent of children and young people in foster care in Tāmaki Makaurau Auckland and Ōtautahi Christchurch were Māori.[297]

251. The Inquiry saw limited evidence about the number and proportion of staff and caregivers who were Deaf or disabled beyond what survivors told the Inquiry, which was that most staff were non-disabled and not representative of those in care. Information on whether staff and carers were disabled, Deaf or blind, and the proportion of these staff and carers to people in care, was not regularly collected by government agencies or the faiths.

252. The Inquiry heard that a lack of Deaf staff contributed to the neglect of Deaf culture and a failure to provide adequate education to Deaf children.[298] This was compounded by the State policy banning sign language until 1969, with oralism being standard practice at all Deaf schools for much of the Inquiry period. For example, at St Dominic’s School for the Deaf (Catholic) in Aorangi Feilding there were no Deaf teachers and children were not taught to sign. Instead, the focus was on addressing their perceived impairment through oralism and speech therapy.[299]

I parea tonu ngā kaimahi me ngā kaiatawhai i te paku tonu o ngā rawa tautoko
Staff and carers were often compromised by under resourcing

253. Understaffing contributed to abuse and neglect in care through staff being overworked, tired and under pressure which affected their ability to provide individualised care, and led to emotional, physical, and educational neglect of people in care. It also contributed to abuse and neglect through inadequate oversight or supervision of staff which provided abusers with opportunities to abuse or neglect people in their care.[300]

254. Robin Wilson, former Director-General of Social Welfare told the Inquiry:

“… there was insufficient recognition of the need for more resources in the residential field. There were insufficient staff and they were not well trained”.[301]

255. Understaffing in institutions was a common problem, including at psychopaedic and psychiatric institutions,[302] community mental health settings,[303] residential homes[304] and some faith-based boarding schools.[305]

256. Many staff said they felt overworked, under pressure and tired due to understaffing.[306] A 1977 Ministerial inquiry into faith-run care services reported “dangerously low staffing levels” in children’s residential facilities and noted “two recent examples of experienced, dedicated, and normally highly reliable and competent staff breaking down under the pressure placed on them”.[307] When Anthea Raven joined the Department of Social Welfare in the 1980s, most social workers “had around 60 active files and some of those may have involved a number of children from one family.”[308] In 1983 it was reported that a social worker’s “caseload should be limited to eight at any time”.[309]

257. A 1986 review of psychiatric and psychopaedic hospitals made a direct link between understaffing and neglect of patients, noting that insufficient staff numbers led to “deficiencies in dignity and in the basic elements of appropriate care”.[310] The review also found that:

“Staff shortages and low morale seriously affect patient care and … lead to lack of awareness and general acceptance of substandard conditions ... staff often appear defeated and convey an air of resignation.”[311]

258. Some staff from psychiatric institutions told the Confidential Forum for former in-patients of psychiatric hospitals about having “a lack of time for kindness”.[312] The 1996 second Mason inquiry into mental health services in found that “multi-disciplinary staff shortages have resulted in lower standards of care.”[313]

259. Some survivors were sexually or physically abused at night when staffing levels were low, with only one staff member on duty.[314]

260. Some staff expressed concern of the safety risk of low staffing levels and inadequate supervision.[315] A 1999 review found night staff were working alone at Kingslea Residential Centre in Ōtautahi Christchurch despite this being against policy at the time.[316]

261. The Kohitere Boys’ Training Centre Annual Report 1964 noted that teacher shortages at the school “meant that little work could be done with boys who were assessed as ‘backward readers’ or otherwise having educational problems”.[317] Former social workers said understaffing often meant that they did not have enough time to work with whānau and sometimes ended up “cutting corners”, such as visiting children in care less frequently than they were supposed to.[318]

262. Up until the 1990s, boarding students at Wesley College (Methodist) school hostel in Pukekohe had inadequate adult supervision overnight and prefects / senior students were responsible for supervision and discipline of junior students.[319] The dormitory prefects and senior students in the hostels were responsible for much of the abuse that occurred at Wesley College, usually initiated as a punishment or a way to maintain obedience from the junior students.

263. Senior students and prefects at Wesley College should never have been placed in a position where they were responsible for supervising and discipling the younger students. These senior students and prefects were not adequately trained or supervised to be in positions of authority. Some adults at the college were aware of the hierarchical culture causing harm to students and did not do enough to stop it. These factors contributed to the school’s culture of violence and led to the tradition of the “Wesley Way”.

264. At the Inquiry’s Faith-based Institutional Response Hearing when General Secretary of the Wesley College Board Chris Johnston was asked about what led to inadequate supervision, he said:

“I can speculate that it was due to finance. I know pre- integration, and integration for Wesley was in 1976, that the reason for integration was that Wesley College could not afford to maintain as a private school. That’s my speculation, you know, affording the additional staff.” [320]

265. Reverend Faulkner also told the Inquiry that when he was a student at Wesley, “most of the outside of school time and during the weekends there was one adult in place for 200 students.”[321]

266. Throughout the Inquiry period care work was not valued by society. This inadequate recognition contributed to conditions where staff and care workers were not appropriate or appropriately trained, were underpaid, experienced poor working conditions, and were otherwise not supported to provide safe and therapeutic care. These factors contributed to environments in which abuse was more likely to occur.

Kō rātou o te ao whakarato me ngā ope taua te momo i tohia hei kaitoko atawhai
Staff with service and military backgrounds were recruited to deliver care

267. Some care facilities actively recruited staff with service backgrounds. For example, in 1978 the New Zealand Herald featured an advertisement for an assistant housemaster to work at Ōwairaka Boys’ Home in Tāmaki Makaurau Auckland, stating that a person “with a service background or work with young people would be most suitable” and no academic qualifications mentioned.[322] That same year, the Auckland Committee on Racism and Discrimination showed that eight of fifteen of the staff employed at Ōwairaka had an armed services background, with nine staff having no high school or other academic qualifications:

“… we are staggered by the emphasis on military background compared with that on educational qualifications.”[323]

268. Robin Wilson, who was the Director-General of Social Welfare in 1992,[324] told the Inquiry that people with military backgrounds were hired to work in institutions because they were available and they understood discipline. In his view:

“it wasn’t altogether negative, there were some very, very good people, but people that come from the military have the adage of discipline and requiring respect and all that kind of thing. When faced with a great mob [of residents], they didn’t know quite what to do [with] them.”[325]

269. He explained that at Ōwairaka, several staff “were ex-military and that was the way they actually operated” which he acknowledged was “terribly bad social work practice”.[326]

270. Having a service background did not mean that staff were inherently abusive. Survivors of social welfare care settings with a high proportion of ex-service staff told the Inquiry there was an “army mentality”[327] with strict regimes and excessive punishments in facilities including Epuni Boys’ Home in Te Awa Kairangi ki Tai Lower Hutt,[328] Kohitere Boys’ Training Centre in Taitoko Levin,[329] Ōwairaka Boys’ Home in Tāmaki Makaurau Auckland,[330] Waikeria Borstal near Te Awamutu,[331] and Rangipo Prison Farm corrective training facility near Tūrangi.[332]

271. Māori and Pākehā survivor Jonathon Stevenson (Kāti Māmoe, Kāi Tahu) said that most of the staff in the youth unit at Waikeria Borstal near Te Awamutu were “Vietnam veterans and crazy sadists who wanted to hurt us”.[333]

272. Former residential staff member, Ken Cutforth, described the principal of Ōwairaka Boys’ Home, Arthur Ricketts, as a “military man” who took the approach of “line up and do as you’re told, don’t answer back”. Ricketts ran staff training seminars, which resulted in his regimented leadership methods spreading to other institutions, like Epuni Boys’ Home and Hamilton Boys’ Home. Ken Cutforth said that Ricketts “became an exemplar to follow for some principals”.[334]

He ngoikore nō ngā mahi ako, whakawhanake mahi tokonga atawhai
Inadequate training and development to deliver care

I poto tonu te ako me te whakawhanake kaimahi, kaiatawhai ki te mahi atawhai ake
Staff and carers lacked training and development specific to care

273. Many staff and carers did not have the training and development needed for their roles and the demands they faced in care settings, particularly in overcrowded and under-resourced facilities.

274. For regulated care professions like medical professionals and teachers, training, development and vetting could form part of their registration requirements.

275. Most staff and carers (including volunteers) were unregulated. Until the late 1980s, employment policies and practices were generally left to each care setting to decide what was needed. Some departments would set broad, process-based requirements through service contracts.[335] From the late 1980s, different settings had different legal obligations. For example, from 1989 the Director-General of Social Welfare had a legal duty to ensure that people delivering social services received adequate training and complied with appropriate standards.[336]

276. In disability and mental health settings, and in Deaf settings, there were numerous reports of a lack of training of both clinical and non-clinical staff and concerns about how that affected children, young people and adults in care.[337] The second Mason inquiry into mental health services in 1996 found a lack of trained staff, particularly in child and adolescent mental health.[338] training was provided, it sometimes taught techniques that were not appropriate for a supportive care environment.[339]

277. Referring to the recommendations on patient rights in the 1983 Gallen Inquiry, the Mason Inquiry said the changes in the Mental Health (Compulsory Assessment and Treatment) Act 1992 that provided better protection for patients and should have reduced inpatient admissions, required significant staff training and resourcing to be effective. That training and resourcing had not happened. The necessary community-based services had not been set up and as a result hospital admissions were still seen as the mainstay of crisis response.[340]

278. In social welfare settings, staff were often appointed from entirely unrelated backgrounds because of a lack of applicants.[341] Few staff had formal qualifications or were well trained to do the job.[342] Training was often “on the job” and from the 1960s, the Department of Social Welfare began to develop training courses for residential staff. From the 1970s these courses were made compulsory for all new staff, although some of these were short, which limited what could be taught and could not cater for all newly recruited staff.[343]

279. A 1981 study on social work, prompted by a concern that “the standards of training for social service workers were not adequate for the tasks social service workers were required to undertake,”[344] reported that 78 percent of social workers had no professional qualifications.[345] The situation had improved slightly by mid-1990s, when 44 percent of frontline staff and 55 percent of new recruits had the minimum qualification to apply for registration as a social worker.[346] Former Chief Social Worker Michael Doolan told the Inquiry that:

“The absence of training opportunities meant that the managers or principals of [social welfare] institutions in the early to mid 1970s almost always had significant numbers of staff who had little or no training.”[347]

280. The situation was similar for family home carers, who were not always given adequate information on the children and young people they were caring for or enough guidance on their role.[348] The Inquiry was told by carers that what training they did receive only came about six weeks after they started caring and that they did not receive any more training over the years they were foster and/or family home carers.[349]

281. A lack of appropriately selected and trained staff sometimes led to the overuse of restrictive practices and physical violence.[350]

282. Former social worker Mr PY told the Inquiry that, in the 1970s and 1980s, “[n]obody had any training on how to restrain that I was aware of.”[351] He said that at Kingslea Girls’ Home in Ōtautahi Christchurch in the mid-1980s, girls were physically restrained at times and “sometimes that was more physical than it possibly needed to be”.[352] A 1985 report to the Minister of Health found that with proper training and enough staff, seclusion in psychiatric and psychopaedic hospitals would be unnecessary.[353]

Te ako me te whakawhanake i ngā takinga pūnaha taurima ā-whakapono
Training and development in faith-based care settings

283. Across all faiths investigated, there was a lack of training or ongoing development for those in leadership positions.

284. Inadequate resourcing and a lack of training contributed to the abuse and neglect of children and young people in Catholic institutions such as Sunnybank Boys’ Home near Whakatū Nelson and St Joseph’s Orphanage in Te Awa Kairangi ki Uta Upper Hutt. The Inquiry heard from many survivors that staff would use restrictive and violent practices to manage the behaviour of children and young people.[354] Sister Sue France stated that a lack of resourcing and training contributed to abuse within the Catholic Church:

“the lack of resources, of people being put in positions where they should not have been put in positions of care of children, or in situations where they were ill-trained for the work that they were doing.”[355]

285. Cardinal John Dew acknowledged the failure to provide training for those preparing for certain aspects of religious life or priesthood:

“Historically, there was no training on the importance of boundaries and training regarding appropriate behaviour for those preparing for the religious life or priesthood. Nor was there the safeguarding training, or safeguarding policies that are now a key part of our church.”[356]

286. Cardinal John Dew also accepted that the lack of training to prepare clergy and religious (members of religious orders) for the isolating and demanding role has contributed to the abuse within the Catholic Church:

“I believe that historically many individuals within the Church may have been ill equipped to deal with mental health issues and loneliness which may have contributed to their actions in harming others.”[357]

287. During the Inquiry’s Faith-based Redress Hearing in March 2021, Anglican Bishop of Christchurch, Reverend Dr Peter Carrell, acknowledged the failure by the Anglican Church to implement boundary training for its clergy:[358]

“I became the Ministry Educator in 2001 in the Diocese for Nelson. My memory is that we did not have a systematic programme for regular boundaries training. In hindsight that was a mistake. We should have had that. … I think there was a complacency that we were basically a set of good people, good clergy, not so much that we didn’t need boundaries training but that it wasn’t an urgent priority as we were seeking to offer other forms of—I mean other things that were also important in training our clergy.”[359]

288. Colonel Gerry Walker told the Inquiry that the Salvation Army had a “Safe to Serve” document from around 2010 that “captured the training that was required, it captured the signs [of abuse] to look for, the training needed, who needed training, the monitoring…[and] auditing of that”. He said he did “not recall that there was anything as clearly documented as that” before 2010. [360]

289. In 1959, the Methodist Church appointed a Commission to examine the Church’s practice of care of children and delivered a report to the Methodist Conference in 1961. The recommendations to the Conference included ensuring that those providing care for children were adequately trained and resourced. The Methodist Church failed to implement the recommendations consistently across all churches, which meant it missed an opportunity to implement and strengthen its safeguarding practices and the way it cared for children.[361]

290. Plymouth Brethren Christian Church told the Inquiry that Elders are not required to undergo any specific training and are not subject to any formal supervision or oversight. They are, however, expected to be familiar with the scriptures and the ministries of current and former senior leaders of the Church.[362]

291. Presbyterian Support Central acknowledged that, as identified from the available records, there did not appear to have been robust recruitment and vetting processes while its Berhampore Home in Te Whanganui-ā-Tara Wellington was operating and there is not evidence of training for staff about safeguarding. The organisation told the Inquiry that, had there been oversight, safeguarding, supervision and appropriate training, some of the abuse could have been prevented.[363]

292. When Gloriavale Christian Community was asked whether its leaders were required to undergo training such as boundaries training, they said that they have recently applied for leaders and managers to attend training programmes for company directors and trustees. This suggests there was no training and development specific to care during the Inquiry period.[364]

He kūiti kāhore rawa atu rānei akonga e mōhiotia ai ngā tohu o te mahi tūkino i ngā pūnaha taurima
Limited or no training to identify signs of abuse and neglect in care

293. Before the 1980s, there was limited training and development of staff and care workers to identify signs of abuse and neglect in care.[365] From the 1980s onwards, most care settings began developing their own guidance and training, initially focusing on sexual abuse.

294. Social workers started to receive formal training on sexual abuse in the 1980s. A 1983 circular issued by the Department of Social Welfare noted that “in recent years the Department has actively encouraged staff, both formally through staff training and in particular through a series of seminars on child abuse, and informally through discussion between H.O. [head office] and district staff, to facilitate and participate in multi-disciplinary case conferences on child abuse cases.”[366]

295. The Residential Social Work Induction Training Programme, which began in 1984, included brief definitions of physical abuse and neglect and sexual abuse at the back of its fourth module, Understanding Human Needs and Development.[367] Its guidance on identifying and preventing sexual abuse is limited to noting that “often it is difficult to detect sexual abuse … [t]he best indicators are, short of the child telling someone, a sudden change in behaviour, signs of emotional disturbance, unexplained sudden crying and excessive nervousness.”[368]

296. In 1984, the Department of Education issued guidelines on how to deal with “cases of suspected sexual abuse of pupils” and how to investigate and report allegations of abuse.[369] Updated guidance was issued in 1989.[370] In 1997 the Ministry of Education issued a circular reminding school boards of trustees that they had to implement policies and procedures to ensure that “staff were familiar with ways to prevent, recognise and respond to abuse”.[371]

297. The Department of Health issued Child Abuse Guidelines for Health Services in 1992 to supplement area health boards’ own policies and processes on identifying and responding to signs of abuse and neglect:

“The safety of the child is paramount. Health service providers must therefore ensure that staff are provided with a basic knowledge and understanding of the indicators of child abuse, and the appropriate reporting procedures to follow.”[372]

298. From 1995, the Director-General of Social Welfare had a statutory duty to promote, by education and publicity, professional and occupational awareness of child abuse, ways to prevent it and to report it.[373]

Ko te hunga i ngā pūnaha taurima i tukia tonu e te ngoikore o ngā tikanga arataki i ngā kaimahi me ngā kaiatawhai
People in care often bore the brunt of poor supervision of staff and carers

299. Poor supervision or performance management contributed to abuse and neglect because it became accepted and staff and carers were not held to account for abuse or neglect.

300. A culture of using physical violence against children, young people and adults in care was so normalised in some care settings that staff found it difficult to intervene when they witnessed abuse or were ostracised if they complained.[374] Tā Kim Workman told the Inquiry about his experience of visiting Kohitere Boys’ Training Centre in Taitoko Levin as a Youth Aid Officer in the 1970s:

“In later years, I thought about why I didn’t do more to address the situation; to ‘blow the whistle’; report on what I knew and call for an investigation. If it did occur to me, I would have put the idea quickly out of contention. The culture was such that I would not have been supported. Moreover, I would have been branded a ‘stirrer’ and secured my place as an ‘outlier’ within the police organisation.”[375]

301. When staff did not agree with normalised violence or derogatory treatment of people in care, they felt under pressure to either conform or leave.[376] This meant that the staff who did remain could become increasingly desensitised to abuse and neglect because no one had been able to stop it.[377]

302. Neglect and physical and emotional abuse was so common in some institutions that it became invisible to staff. Paul Milner, who visited the Kimberley Centre near Taitoko Levin, a psychopaedic hospital for children with learning disabilities, for around three years in his role as a disability researcher, told the Inquiry:

“In the culture that I witnessed, it was next to impossible for anybody to do anything more than walk away. That is the nature of an institution. The things that I was completely affronted by and recognised immediately as abuse, I no longer saw.”[378]

Kāhore te Tiriti o Waitangi i kitea i ngā kaupapa me ngā tikanga hautū mahi
Te Tiriti o Waitangi was absent in employment policies and practices

303. During the Inquiry period, there was no legislative direction that employment policies or practices should incorporate te Tiriti o Waitangi or give effect to the rights guaranteed to iwi and hapū in te Tiriti o Waitangi. It was left to government agencies and individual institutions to decide whether and how to incorporate te Tiriti o Waitangi into their employment policies and practices regarding vetting, recruitment, training and development of staff and other carers.

304. The Inquiry notes that section 56(2) of the State Sector Act 1988 included an obligation for a chief executive of a department to operate a personnel policy. That policy needed to contain provisions “generally accepted as necessary for the fair and proper treatment of employees”. Section 56(2)(d) said the policy should recognise:

“(i) the aims and aspirations of the Maori people; and
(ii) the employment requirements of the Maori people; and
(iii) the need for greater involvement of the Maori people in the Public Service”.[379]

305. The Inquiry did not see any employment policies or practices that explicitly incorporated te Tiriti o Waitangi. The State was aware from at least 1982 that there was a lack of diversity in the public service, and that recruitment and training programmes were needed to increase diversity and appoint people directly into positions of seniority and responsibility.[380]That this was not effectively addressed represents a missed opportunity to benefit from the Māori thinking, approaches and values that greater involvement of Māori employees in care settings and policy agencies would have bought. This was contrary to te Tiriti o Waitangi principles of tino rangatiratanga, partnership, active protection, good government and options as set out in Part 1 of this report.[381]

He akonga i kitea he mea i panonihia e pā ana ki ngā tikanga hautū mahi
Lessons identified and changes made to employment practices

306. The State learned that it needed to regulate the recruitment and training of staff and carers in care settings. It began to take steps to do this from the late 1970s, primarily through internal policies in social welfare and education settings.

307. However, there were no legislative changes during the Inquiry period to make staff vetting mandatory in all care settings, to direct NZ Police on how to respond to vetting requests, or to create serious sanctions for those senior leaders and managers in care settings who knowingly gave abusers with criminal convictions positions in care settings.

308. The State did not make any legislative changes during the Inquiry period to bring a consistent approach across all care settings to recruiting diverse staff and carers, baselines for what constitutes adequate resourcing to prevent or respond to abuse and neglect in care, or training and development requirements to deliver care or recognise the signs of abuse and neglect in care.