309. Effective complaints processes need to be designed for children, young people and adults in State and faith-based care and be easily accessible.[383] Complaints policies should clearly cover how to make a complaint, responding to a complaint, investigating a complaint, support and assistance for complainants, and how to achieve system-level improvements in light of a complaint.[384] Record-keeping requirements are also critical for the effective administration of complaints processes and for providing oversight of decisions made.[385]

310. Absent, inaccessible or poorly implemented complaints processes can perpetuate abuse.[386] Institutional behaviour that undermines complaints processes and contributes to abuse and neglect in care include:

a. use of internal or closed processes that avoid external scrutiny[387]
b. prioritising the reputation of the care facility over the wellbeing and safety of people in care[388]
c. prioritising the abuser’s reputation and/or rights as an employee or member of a union over the wellbeing and safety of people in care[389]
d. failing to refer complaints to appropriate authorities.[390]

311. The first section of this chapter looks at what complaints processes were available to children, young people and adults in care to raise concerns or make complaints about abuse or neglect during the Inquiry period. It relates to clauses 31(b) and 10.2(b) of the Terms of Reference.

312. The second section of this chapter looks at what processes were in place across all care settings to respond to concerns or complaints of abuse or neglect, and how effective these were, including internal investigations into the concern or complaint and referrals for disciplinary or criminal action. It also covers barriers experienced by people in care to raising concerns or making complaints as part of looking at how effective institutional responses to complaints were. This section relates to clauses 31(b) and 10.2(d) of the Terms of Reference.

Ngā kaupapa kōamuamu i te wā o te Pakirehua
Complaints processes during the Inquiry period

313. From 1950 to 1986, there were no legislated rights to a complaints process for children, young people and adults in care in any State or faith-based care setting. It was left to individual care facilities to decide whether to provide people in their care with access to a complaints process.

314. From 1986, the law required social welfare residences to have complaints processes accessible for people in their care. From 1992, the law required people subject to compulsory mental health treatment assessments or orders to have access to complaints processes. All other people in State or faith-based care were reliant on either government agencies or individual care facilities to provide them with access to a complaints process.

315. Like standards of care, complaints processes varied so widely during the Inquiry period that access to an adequate complaints process depended on when someone was in care, where, and whether they were disabled or not.

Ngā kaupapa kōamuamu takinga whaikaha, hauora hinengaro
Complaints processes in disability and mental health settings

316. Until the 1990s, the primary mechanism for children, young people and adults in care in mental health settings to raise concerns or make complaints was through district inspectors and official visitors.[391] District inspectors were required to have medical qualifications, or from 1969 legal qualifications as either a barrister or solicitor and reported to the Director of Mental Health as independent watchdogs of mental health services.[392]

317. Unlike district inspectors, official visitors did not need to be highly qualified but needed to have “impartiality, respectability and social concern”.[393] Official visitors’ main purpose was to act as an advocate or friend for people in psychiatric hospitals. They could escalate issues they observed or concerns that were raised by people in care.[394] Official visitors also reviewed how complaints were managed and made recommendations to hospital management to improve processes.[395]

318. There were initially not enough district inspectors across the country – there were only two in the 1960s, increasing to 27 by 1997.[396] Their role was poorly defined and many people in mental health care settings were not aware of them or how to speak to them. The official visitor role was retained under the Mental Health (Compulsory Assessment and Treatment) Act 1992. Official visitors were appointed in 1993 but were not reappointed in 1996. In 2014, official visitors had still not been re-appointed.[397]

319. After 1992, there was a legislated complaints process for people in care who were subject to compulsory mental health assessments and treatment orders.[398] This was limited to complaints about breaches of their statutory rights. The complaints process ensured that people subject to compulsory orders had access to advocacy, and that all complaints would be independently investigated by either the district inspector or official visitor.[399] If a complaint was substantiated, it had to be referred to the Director of Area Mental Health Services, along with any recommendations. The Director had a legal duty to take all steps needed to fix the complaint.[400] There was also a right of appeal if the complainant was unhappy with the outcome.[401]

320. From 1996, the Code of Health and Disability Services Consumers’ Rights made it clear that anyone in the care of a health and/or disability service provider had the right to complain.[402] Providers were obligated to facilitate the fair, simple, speedy and efficient resolution of complaints. There were clear time-limited procedural steps that providers were required to follow to ensure the complaint was dealt with and complainants were kept informed throughout, including about their rights of appeal.

Ngā kaupapa kōamuamu takinga toko i te ora
Complaints processes in social welfare settings

321. From 1957 to 1986, complaints processes for social welfare settings were contained in the Field Officers Manual and its later versions (including the Social Workers Manual). Like the standards of care set out in these manuals, complaints processes were not accessible to children and young people in care, their family or whānau.

322. In this period, visits from a child welfare officer or social worker were considered the primary way that children and young people in care could raise concerns or complaints. This was reflected in the guidance in the staff manuals, which included best practice guidance on the minimum number of face-to-face visits required. The manuals also set out that concerns or complaints of abuse or neglect should be promptly dealt with and prioritised and that, if the concerns or complaints were considered serious, NZ Police should be contacted.

323. From 1984, it was the principal’s responsibility to develop a formal grievance procedure for complaints processes in social welfare residences.[403] This requirement did not cover foster homes and third-party care providers. The principal had discretion regarding what to include in the grievance procedure.[404] In 1986 it became a requirement for the principal of the residence to inform children and young people in care about the grievance procedure and how they could lodge a complaint.[405] The 1989 Care and Protection Handbook and Youth Justice Handbook did not include information on complaints processes.[406]

324. In 1989, the Human Rights Commission conducted a review of secure care in social welfare residences and found that very few had formal complaints or grievance procedures in place, despite being legally required. [407]

325. The 1996 updated Residential Care Regulations gave every child or young person in a residence the right to access the grievance procedure[408] and introduced the right to an independent advocate when making a complaint.[409] The Regulations also established grievance panels and made it compulsory for every residence to have one.[410] The key functions of a grievance panel were to monitor compliance with the grievance procedure and review decisions made by the manager about complaints and any punishment or sanction imposed on a resident.[411]

326. Third party providers had to have a written policy for dealing with complaints, which had to be given to and explained to children and young people in care and their families.[412]

327. The Care and Protection Manual 1996 set out details of the Commissioner for Children’s complaints service, which was established so that the public could bring issues of concern relating to either individual children or groups of children to the Commissioner’s attention. When reviewing complaints, the Commissioner could give opinions on whether the complaint was justified or make recommendations, but did not have the power to enforce these.[413] Child, Youth and Family had an agreed protocol for the management of complaints received by the Commissioner for Children.[414]

Ngā kaupapa kōamuamu takinga mātauranga
Complaints processes in education settings

328. From 1950 to 1989, there were no legislated requirements for children and young people in education settings, including special schools for Deaf students, to have access to a complaints process.[415] Like standards of care, it was left to schools to decide whether to provide a complaints process. From 1989, it was left to a State or State-integrated school’s board of trustees to decide whether to have a complaints process, taking into consideration any guidance from the Ministry of Education.[416] For private schools, school hostels and boarding houses, there was also no specific legislative direction on complaints processes for children and young people in their care.[417]

329. For Deaf students in special schools or classes, there were no legislated requirements for access to a complaints process. The Inquiry saw no evidence of a documented complaints process at either Van Asch College in Ōtautahi Christchurch or Kelston School for the Deaf in Tāmaki Makaurau Auckland until 1994.[418] There was no reference to complaints or complaints policies in any of their annual reports to the Department of Education, nor any indication of Departmental oversight of complaints.

330. From 1994, Kelston School for the Deaf had a general complaints policy that covered complaints made against staff, although it was focused more on protecting staff than people in care. The policy had nine stated purposes, of which the first two were “to ensure minor concerns are not blown out of proportion putting the staff member under undue stress” and “to ensure individual staff members are not unfairly harassed or unreasonably impeded from carrying out their allotted tasks”.[419]

Ngā kaupapa kōamuamu takinga whakatika, mauhere ā-ture
Complaints processes in transitional and law enforcement settings

331. From 1950 to 1999, there were no legislated requirements for people in transitional and law enforcement settings to have access to a complaints process. NZ Police’s General Instructions were silent on complaints processes for children, young people and adults in their care.[420]

Ngā kaupapa kōamuamu takinga pūnaha taurima ā-whakapono
Complaints processes in faith-based care settings

332. From 1950 to 1999, there were no legislated requirements for children, young people and adults in faith-based care to have access to a complaints process. Each faith-based institution decided whether to provide a complaints process, and what that would consist of.

333. Survivors of Gloriavale Christian Community were actively prevented from reporting their abuse. Overseeing Shepherd of Gloriavale Howard Temple conceded at the Inquiry’s Faith-based Institutional Response Hearing that the community’s policy documents prevented reporting of crimes to secular agencies, including to NZ Police, and that everyone in the community was aware of this policy.[421] The policy limited contact with the outside world,[422] including State agencies, and reduced opportunities for oversight and the disclosure of abuse. It was in place from 1989 to 2002.[423]

334. The Salvation Army’s Orders and Regulations provided a procedure for improper conduct, but this focused on the discipline of staff rather than on being an accessible complaints process for people in its care.[424] In 1989, the Salvation Army established the Officer Review Board, which assisted the Territorial Commander with disciplinary matters and required that certain complaints must be investigated. In 1991, the Salvation Army leadership in Aotearoa New Zealand implemented an Official Minute that provided guidelines on some situations including child abuse. The Official Minute provided that a report with recommended action be submitted to Territorial Headquarters to ensure disciplinary consistency across the Territory.

335. The Salvation Army introduced the Sexual Misconduct: Policies & Complaints Procedures Manual in 1999. The manual details the processes for complaints and investigations of sexual misconduct. All criminal sexual behaviour must be reported to the Secretary for Personnel and the complainant is also advised to report their complaint to NZ Police.[425]

I te nuinga o ngā wāhi mahi kāhore he kaupapa whakautu kōamuamu
Most settings did not have processes in place to respond to complaints

Te whakautu kōamuamu takinga whaikaha, hauora hinengaro
Response to complaints in disability and mental health settings

336. In disability and mental health settings, there was little evidence of internal processes for investigating and responding to reports of abuse and neglect in care before the 1980s, although there were external processes in place (such as district inspectors, official visitors, and the Health and Disability Commission).

Te whakautu kōamuamu takinga toko i te ora
Response to complaints in social welfare settings

337. In social welfare settings, the process for responding to concerns or complaints was generally set out in the Field Officers Manual, and subsequent versions, including handbooks, with clear guidance on what to do when the concern or complaint was serious:

“Whenever there is any reason to believe that a child’s life is in danger, or that he is being subjected to serious neglect or cruelty, the investigation of such complaints must take precedence over all other duties. If the case is sufficiently serious, the officer has not only the right, but also the duty, to make a complaint and obtain and execute a warrant, removing the child to a place of safety until inquiries can be completed and the Court can determine what action should be taken…”[426]

338. The 1957 Field Officers Manual reminded Child Welfare Officers of the importance of contacting NZ Police, as it was “a criminal offence to ill-treat, neglect or fail to provide a child with the necessaries of life”.[427]

339. From 1996, processes for responding to complaints in social welfare residences were set out in the Children, Young Persons, and their Families (Residential Care) Regulations.

Te whakautu kōamuamu takinga mātauranga
Responses to complaints in education settings

340. In education settings, including special schools for Deaf students, formal processes for investigating and responding to reports of abuse were generally not in place until the mid-1980s. These were generally left to individual schools to develop, with no specific requirement or direction in legislation.

Te whakautu kōamuamu takinga whakatika, mauhere ā-ture
Responses to complaints in transitional and law enforcement settings

341. Between 1950 and 1989, there were no clear processes in place in transitional and law enforcement settings to respond to concerns or complaints about children, young people and adults in their care. From 1989, the Independent Police Complaints Authority could receive complaints alleging any misconduct or neglect of duty by any NZ Police employee, regarding any practice, policy, or procedure of the NZ Police affecting the person making the complaint.[428]

Te whakautu kōamuamu takinga pūnaha taurima ā-whakapono
Responses to complaints in faith-based care settings

342. Most faith-based institutions began establishing processes for investigating and responding to reports of abuse and neglect in their care towards the end of the Inquiry period in the 1980s.[429] The Inquiry saw limited evidence of formal investigative processes within faith-based institutions during the Inquiry period.

343. Before the 1990s, formal processes for responding to reports of abuse had not been established within the Catholic Church.[430] Some church leaders perceived the abuse of children, young people and adults as a canonical crime and a moral failing, not a criminal offence that should be reported to NZ Police. From 1987, leaders within the Catholic Church in Aotearoa New Zealand, the New Zealand Catholic Bishops’ Conference and the Congregation Leaders Conference of Aotearoa New Zealand began to develop processes relating to responding to reports of abuse:[431]

a. In 1987, the New Zealand Catholic Bishops’ Conference released a pastoral letter to priests about sexual misconduct.
b. From 1990 to 1992, the New Zealand Catholic Bishops’ Conference sought advice about a national protocol for responding to complaints of sexual abuse and sexual misconduct, and a “provisional protocol” was established in 1993.
c. In 1995, the Congregation Leaders Conference of Aotearoa New Zealand developed congregational guidelines for cases involving sexual abuse.
d. Te Houhanga Rongo – A Path to Healing was formally adopted as a national protocol in 1998. Although the current and previous versions of Te Houhanga Rongo – A Path to Healing state that the protocol was first “adopted” in 1993, there is no evidence dioceses or religious institutes collectively agreed to any national policy before Te Houhanga Rongo – A Path to Healing in 1998.[432]

344. The Catholic Church provided the Inquiry with various complaints policies it had in existence. This included guidelines on sexual misconduct by clerics, religious and church employees (first issued in 1993 and sometimes referred to as the “provisional protocol”),[433] a 1996 document for congregational leaders detailing the suggested procedures in cases of allegations of sexual abuse by a religious,[434] and St John of God draft guidelines for complaints against brothers 1997.[435] Disciplinary processes in response to clergy and religious who are abusers are discussed in the Inquiry’s interim report, He Purapura Ora, he Māra Tipu: from Redress to Puretumu Torowhānui.[436]

345. As described in the Inquiry's interim report, He Purapura Ora, he Māra Tipu: from Redress to Puretumu Torowhānui, the Anglican Church does not have a national policy document to provide guidance to bishops responding to reports of abuse. Bishops instead rely on part of the church’s code of canons, Title D. Title D sets out the standards of conduct for clergy and others associated with the church as well as the disciplinary process for alleged abusers. However, the focus of this process is on the discipline of clergy and their suitability to continue as a priest rather than the needs of the complainant.[437]

346. The lack of a national policy document led to a lack of consistency and transparency across different Anglican Church care settings. Until the late 1990s, the bishop of the relevant diocese was responsible for dealing with any reports of abuse, but there were no guidelines in place to assist them. The Anglican Church has acknowledged that:

“Responses to reports of abuse historically lacked objectivity and distance. Leaving it up to each Diocese and Bishop to handle its own complaints has led to a lack of consistency and transparency across the Church in this space.

The lack of overarching Church policy or procedure to guide the handling of complaints of abuse is a mistake that we have previously identified. Regretfully, the focus of the Church has been on issues of discipline rather than on survivors.” [438]

347. The Methodist Church had no formal policy for responding to complaints. It described its approach as a traditional legal approach, requiring survivors to first report to NZ Police before it would conduct its own investigation.[439]

348. The Presbyterian Church has accepted that while healing is a part of their complaints process, it is primarily a disciplinary process. The church accepted that the process is not survivor focused, but told the Inquiry that complaints were considered “sincerely and with great care”.[440] At the Inquiry’s Faith-based Institutional Response Hearing, Reverend Wayne Matheson, the Assembly Executive Secretary of the Presbyterian Church of Aotearoa New Zealand, explained that the church’s complaints process is:

“… primarily aimed at disciplining the person if the charge is proved, rather than anything else”.[441]

349. The Salvation Army did not have any standardised processes in place to respond to complaints made by those within their care. It addressed complaints case by case.[442]

350. The Gloriavale Christian Community had no formal or consistent processes regarding the disclosure of abuse.

351. The Plymouth Brethren Christian Church provided evidence to the Inquiry about how it responds to reports of abuse, stating that the Church “does not have any policies (written or otherwise) relating to claims [reports of abuse] or redress processes at either a national or assembly level”.[443] However, based on a survey of assemblies, the Church provided the Inquiry with a summary of how “any allegations of abuse in any context … have been or would be expected to be managed and addressed”.[444] The Church explained how it responds to “unacceptable conduct”, which was geared towards forgiveness and reconciliation, as its mechanisms for responding to abuse allegations were based on religious doctrine. For example:

“When a member engages in behaviour that is inconsistent with Christian principles according to the holy scriptures, elders and other members work to help them to address that behaviour and its underlying causes and support them to overcome it and remain in the church (Galatians 6 v 1)”.[445]

352. Plymouth Brethren Christian Church told the Inquiry that if a member’s problematic behaviour is ongoing and poses a risk to the spiritual, psychological and/or physical wellbeing and safety of themselves or other members, he or she may be “confined” for a period while elders investigate and take steps to address the situation. While confined, a member remains in the fellowship of the church, but is asked not to attend church meetings and not to have unnecessary contact with other church members. Depending on how serious the allegations are and whether they are substantiated, a perpetrator may be withdrawn from.[446] In the majority of cases, the issues are resolved and the confined member is restored to full fellowship after a short period.[447]

I tūtakina te hunga i ngā pūnaha taurima e te mahi a te pouārai i hiahiatia ai te tautoko ā-whānau iwi kē, Māori mai, reo kaikōkiri hoki
People in care faced barriers and needed family, whānau or advocacy support

353. For many children, young people and adults in State and faith-based care, the absence of an accessible complaints process and clarity on how their complaint would be responded to was a significant barrier to raising concerns or making a complaint about the abuse or neglect they were experiencing.

354. Without a known, clear and accessible complaints process, people in care were reliant on others, particularly those in positions of power, to intervene on their behalf and raise concerns with senior staff and managers. For many people in care this could have been a trusted member of their family, whānau or community, or access to an independent advocate.

355. However, children, young people and adults in care were often prevented from seeing their families, either through not being allowed visits or being allowed only short and infrequent visits.[448] In many psychiatric and psychopaedic institutions, families were actively discouraged from visiting their loved ones in care and other forms of family contact were restricted.[449] Connections between siblings in care, who may have been able to speak up for each other, were at times deliberately suppressed by staff and carers.[450]

356. A lack of access to an advocate was a barrier for many people in care.[451] In 1989, the Human Rights Commission recommended that independent advocates be appointed for each social welfare institution, to ensure people in care knew about their rights to complain, and to make complaints on their behalf.[452] However, this did not become a requirement until the Regulations were updated in 1996.[453]

357. Care facilities where people in care do not have access to a trusted adult carry a higher risk of abuse, including sexual abuse.[454] Without access to a trusted adult, people in care who were being abused or neglected often felt isolated and were unsure who to tell what was happening to them. This was exacerbated when staff and carers deliberately prevented people in care from having strong connections with family, whānau, communities, or independent advocates, or minimised their contact with them. In some religious communities, like Gloriavale, access to adults or advocates outside the community was actively discouraged, limiting survivors’ ability to disclose what had happened to them.

358. Many people in care were not aware of their rights and of what to do if they felt these were being breached, even when the institution was required to tell them about their rights.[455] When complaints mechanisms were available, some people in care were not made aware of them. Māori and Pākehā survivor Jonathon Stevenson (Kāti Māmoe, Kāi Tahu), who was sent to Waikeria Borstal near Te Awamutu in the late 1980s when he was 15 years old, told the Inquiry:[456]

“There was no-one for us to complain to. They didn’t tell us about the Office of the Ombudsman or about the prison inspector. It was illegal not to inform us about our rights”.[457]

359. For Deaf and disabled survivors, barriers to making complaints were exacerbated by a lack of support for communication needs.[458] This was an issue in psychopaedic institutions where many residents needed additional communication support and some had no speech at all.[459] The lack of sign language in Deaf schools and the predominance of hearing staff meant that Deaf survivors were limited in their ability to share their experiences of abuse. NZ European survivor Mr JS, who attended Van Asch College in Ōtautahi Christchurch in the late 1970s and early 1980s, told the Inquiry:

“There were so many times that we tried to complain and tell people what happened to us… Most of the time the same thing would happen. You would be in the room with two hearing adults and you could see that they were talking to each other but you could not understand what they were saying.”[460]

360. Tāngata Turi Māori had no access to trilingual interpreters who could communicate in English, te reo Māori and New Zealand Sign Language to help them with their complaints.

361. For tamariki and rangatahi Māori in State and faith-based care, racism acted as an additional barrier to reporting abuse.[461]

362. For some Pacific Peoples in care, additional barriers to reporting abuse included having to consider the impact of doing so on their family’s relationships and community support networks.[462] Shame and the risk to a family’s reputation were strong barriers to disclosing abuse among Pacific survivors.[463] For example, making a complaint would challenge the Samoan concept of fa’aaloalo, or respect for carers, elders and authority figures, and bring “shame and hostility to the [survivor’s] family”. [464] The lack of a culturally appropriate process contributed to barriers to reporting abuse.[465] The Inquiry also heard evidence that complaint processes are hard to navigate and there are language barriers.[466]

363. Part 5 of this report described the fear that prevented many children, young people and adults in State and faith-based care from raising concerns or making a complaint. This included a fear of severe punishment for ‘narking’ or speaking up,[467] a fear of not being believed,[468] and a fear of excommunication from faith communities.[469] Survivors of faith-based boarding schools for boys told the Inquiry that the ‘no narking’ rule went hand in hand with the culture of violence and was a significant barrier to reporting abuse or neglect.[470] The Inquiry heard that there was no point in complaining to staff because the culture was one of ‘stand up and be a man’, and that students had no choice but to take the beatings and tolerate the abuse – if they showed any weakness they would be further picked on.[471]

364. In all care settings, whakamā or shame was a barrier.[472]

365. Faith-based settings had unique barriers to reporting abuse or making complaints.[473] There was a strong preference for secrecy and silence, which created additional barriers to making complaints because survivors had little hope that any disclosure of abuse would be dealt with appropriately or lead to those responsible being held to account.[474] Within the Plymouth Brethren Christian Church, people who did make complaints told the Inquiry they were often disbelieved, punished or ostracised.[475]

366. In some faith-based settings, religious doctrine or documents created a barrier. Howard Temple, the current Overseeing Shepherd at Gloriavale, acknowledged that the Gloriavale Doctrine of Unity made it very difficult for members to raise concerns because if they were in conflict with a person, they could not be in unity with that person.[476] It was also accepted that the Doctrine of Submission may have prevented children from raising allegations of abuse.[477]

367. By the end of the Inquiry period, most care and protection and youth justice residences had a grievance procedure in place, and concerns shifted to their effectiveness in practice. A 1999 review of operational care practice at Kingslea Residential Centre in Ōtautahi Christchurch found there were numerous difficulties with how the grievance procedure operated. This included staff deliberately delaying providing the grievance form to the resident, residents having to ask staff members for complaint forms, delays in investigating grievances, and the lack of an external system for randomly checking that residents were able to access the grievance procedure.[478]

I te nuinga o te wā kīhai ngā purapura ora i whakaponohia mo te whāki mahi tūkino
Survivors were generally not believed if they reported abuse and neglect

368. The failure to believe survivors who reported abuse and neglect was a common theme across all State and faith-based care settings. Expert witness Denis Smith told the Inquiry:

“…I would often be told by some of my superiors that children were liars. Within that background, it was difficult to take steps to protect children under our care who complained about their treatment…”[479]

369. Another common theme was calling people who made complaints liars or troublemakers.[480] Several survivors said staff and carers “did not listen,”[481] dismissed their complaint[482] or appeared annoyed[483] when they tried to report abuse.

370.  The Inquiry also heard from most survivors that made complaints that they were not believed. [484] Māori Survivor Mr HZ from Marylands School told the Inquiry he had complained many times about abuse but was always disbelieved: 

“I told … my teacher at Marylands, that the Brothers had been sexually abusing the boys. She didn’t believe me though. She told me that Brothers don’t do things like that and that I must stop lying.  …I also told three social workers from the Department of Social Welfare that I was being abused but they didn’t believe me.” [485]

371. Australian and New Zealand Survivor Leonie Jackson told the Inquiry that: 

“I have told so many priests about the abuse I have suffered in confession and have only received penance in return. No one ever told me it was a crime or gave me advice, so I believed it was my sin to carry.”[486]

372. Complaints of abuse by Deaf and disabled people were often minimised or dismissed, underpinned by societal attitudes of ableism and disablism.[487] Staff did not always believe or denied complaints from Deaf or disabled people in care.[488] For example, NZ European survivor Mr JS tried numerous times to raise concerns about serious sexual abuse at Van Asch College in Ōtautahi Christchurch, where all of the staff were hearing, but he was not believed:

“We tried so hard to always tell the truth but no one ever believed us”.[489]

373. In 1988, a social worker raised concerns about the Department of Social Welfare’s approach to allegations of sexual abuse in foster care:

“… [people in foster care] are often already labelled as a delinquent and it is very easy to dismiss what they are saying. In my client’s case there was an onslaught upon her credibility. I was told by a number of my colleagues that she was a liar, untrustworthy, that she was ‘no innocent’ and given to sexual fantasising”.[490]

374. Complaints of sexual abuse where the abuser was the same gender were sometimes characterised as a “homosexual experience” or “homosexual relationship” rather than as abuse, even where it was clear that the survivor could not legally consent or where the abuser was in a position of power.[491] These attitudes meant that survivors were less likely to be believed if they disclosed abuse or neglect, and likely to consider that what happened to them was not abuse.

375. Survivors of faith-based care told the Inquiry that many people did not believe that a person with religious status could commit abuse.[492]

376. Cardinal John Dew accepted that failures were made by the Catholic Church when responding to reports of abuse before 1985:

“I also acknowledge that in that period cases weren’t handled well, that sometimes they were denied and I said in that apology people weren’t believed … And that was a terrible time and it should never ever have happened like that.”[493]

377. European survivor Dr Christopher Longhurst, who made several sexual abuse complaints to the Catholic Church’s National Office for Professional Standards, expressed his view that “character assassination of a victim is not unusual in the Catholic hierarchy after a victim has been abused and even before any disclosure of that abuse is made”.[494] In his role as the leader of the Survivors Network of those Abused by Priests (SNAP), he reported that several members told him that the Catholic Church’s response “demonstrated denial, disbelief, concealment, cover up, justifying, lying, diverting, stalling, masking culpability by offering partial or weak apologies [and the] protection of perpetrators”.[495]

378. From 1982 to 1983, when Brother Richard Dunleavy was Vice-Provincial of the Marist Brothers, he received a complaint about Brother Giles Waters (Kevin Waters) discussing “sexual matters with his primary school class” at Xavier College in Ōtautahi Christchurch.[496] Brother Richard decided the appropriate response was to send Brother Giles to a Marist Renewal Course for Older Brothers in Rome. When Brother Giles returned from Rome in 1985, he was appointed to teach a Form 1 and 2 class in Gisborne.[497] In 1986, Brother Giles was sent to Sacred Heart College in Tāmaki Makaurau Auckland to assist with administrative work, where he remained until 2004. In 1998, a serious complaint of sexual abuse was received by the Marist Brothers concerning Brother Giles.[498] Further complaints of sexual abuse were received from 2004.

379. Presbyterian Support Central acknowledged its past leadership was historically defensive in its approach to complaints. In the early 2000s, complainants were often encouraged to take the issue to court.[499] There were also occasions where the organisation questioned the credibility of the complainants.[500] Presbyterian Support Otago acknowledged that, in the past, it responded initially to complaints with hesitation or disbelief.[501] While its intent was to “do the right thing”, Jo O’Neill (CEO of Presbyterian Support Otago) accepted that “historically people struggled to believe that anyone given authority to assist in this endeavour was capable of abuse”.[502] Presbyterian Support Otago considers this contributed to the way complaints were poorly handled.[503]

380. The Methodist Church acknowledged “its past and more recent failings in addressing complaints and redress”, noting that “[i]t has not always accepted and acted appropriately on reports of abuse and complaints”.[504] The church also acknowledged that it caused additional harm to survivors when it initially refused to believe them, sought to contest their concerns or looked to refer the complaint elsewhere; and failed to recognise that the church also needed to address the complaint.[505]

381. Survivors who reported abuse in Gloriavale were often disbelieved, blamed for their abuse and subjected to intimidation and shaming by leaders. The treatment of sexual abuse as a sin, rather than a crime, and a focus on forgiveness resulted in the perpetrators’ interests being prioritised over the wellbeing of survivors. It also may have enabled perpetrators to reoffend.[506]

Tērā ngā kaimahi matua i aro kē ki te mana o ngā hinonga me ngā kaitūkino i runga atu i tērā o te hunga i ngā pūnaha taurima
Senior leaders prioritised the reputations of institutions and abusers over people in care

382. In the absence of any legal direction, it was unclear how senior leaders and managers in State and faith-based institutions should handle complaints of abuse or neglect when these intersected with employment processes, professional disciplinary processes, or NZ Police investigations.

383. In practice, many senior leaders and managers made decisions that had the effect of protecting or prioritising their institution’s reputation, or the reputation of the abuser, over investigating the complaint, ensuring the safety of people in care, and holding the abuser to account.

384. In several cases, a senior leader or manager was conflicted by their relationship with the abuser. This conflict of interest contributed to the complaint being handled in a way that effectively protected the abuser rather than the person making the complaint.

385. Pākehā survivor Gloria Ramsay, told the Inquiry:

“…the Church should never be left to investigate its own complaints. It has a one-sided agenda. Clergy first. The ‘faithful’ members of the church who become victims of abuse are at the bottom of their priority.”[507]

I tirohia ngā kōamuamu anō nei he rarunga kaimahi, wāhi mahi rānei
Complaints were often dealt with as employment issues or workplace incidents

386. The Ministry of Education advised school boards in 1997 that in cases of alleged abuse by a staff member:

“The Board must ensure the staff member is treated fairly, according to the terms and conditions of the relevant employment contract, and that the principles of natural justice are adhered to. Close contact should be kept with the Children, Young Persons and their Families Service, and the Police, so the school does not inadvertently undermine or frustrate investigations.”[508]

387. The deference to other processes being followed sometimes had the effect of prioritising the rights and interests of the abuser over those making the complaint. For some survivors, the use of employment processes to deal with complaints felt like abuse was being “tolerated, covered up and/or minimised”.[509]

388. Reliance on employment law generally resulted in senior leaders and managers taking widely different approaches to responding to complaints. There were examples of complaints of abuse being framed as workplace incidents requiring “performance improvement strategies”.[510]

389. There were numerous instances of abusers remaining in their position as part of the employment law process, and in many cases continuing to abuse. There were examples of the State Services Commission sanctioning institutional staff for abuse but allowing them to continue to work, with some staff going on to abuse more people in care.[511]

He maha ngā kaimahi matua, kaiwhakahaere i tautoko i te rīhaina, te hūnuku rānei o ngā kaitūkino ki wāhi kē
Many senior leaders and managers supported abusers to resign or move to a new location

390. There were numerous examples of senior leaders and managers encouraging or allowing abusers to resign, which avoided both responding to the complaint and following employment processes. At the Inquiry’s Faith-Based Redress Hearing in March 2021, Anglican Bishop of Christchurch Peter Carrell told the Inquiry:

“…to resign would be, on the facts then known, an appropriate response by him and would mean that we would not, if you like, force a determination…we would also have been taking care not to construct his dismissal with the potential legal complications that would then ensue. So it would be preferable, if you like, on both counts that he faced up to the situation via his resignation.” [512]

391. Sometimes, senior leaders or managers would simply shift the abuser to another location and used this as reasoning not to investigate the complaint further, called “geographical cure” in faith-based settings.[514] The ability to shift or relocate an abuser required a high level of seniority or authority within an institution or government agency. Sometimes this shift happened without the new institution being told about the risk the abuser posed to children, young people and adults in their care.

392. At times, care was taken to ensure the abuser’s reputation was protected. In 1972, in response to allegations of historical and “current misconduct and offensive behaviour” against Brian Zygadlo, Principal of Margaret Street Girls’ Home in Te Papaioea Palmerston North, Acting Assistant Director of Social Welfare J Kidd decided to transfer him to another social welfare residence:

“Mr Zygadlo has accepted the decision that he must transfer… But Mr Zygadlo (not without justification) feels that the feasibility of such an arrangement [a relieving housemaster role] would be devoid of the credibility his transfer must be seen to have if he is not to be severely personally disadvantaged.

I have today discussed…the possibility of Mr Zygadlo’s request that he should go to Hokio [Beach School] rather than to Kohitere [Boys’ Training Centre]. We agree this would be much more practicable, both in terms of the apparent need there…and in terms of it not being inconsistent with a move that he could have made anyway without disadvantage to his career”.[515]

393. Brian Zygadlo went on to sexually abuse multiple children at Hokio Beach School near Taitoko Levin and has been accused of sexually abusing children at Epuni Boys’ Home in Te Awa Kairangi ki Tai Lower Hutt and Stanmore Road Boys’ Home in Ōtautahi Christchurch.[516]

394. The Department of Social Welfare’s practice of shifting abusers led Ken Cutforth, who was a former staff member of the Department of Social Welfare, to write to the Human Rights Commission:

“What concerns me in these situations is the method whereby the Department, particularly Head Office personnel, appear to ‘cover up’ some situations by transferring the accused staff member to another position (no appeals can be heard on such occasions). The person remains in this new position until the incident is well in the past and the facts about the incident and obscured in people’s memory, and then the staff are afforded promotion to positions where they in turn can select staff.”[517]

395. Ken Cutforth gave four examples of residential staff being transferred to another residence following allegations of abuse against them:[518]

a. Brian Zygadlo: transferred from his role as Principal, Margaret Street Girls’ Home in Te Papaioea Palmerston North to Hokio Beach School near Taitoko Levin, and then to Principal, Stanmore Road Boys’ Home in Ōtautahi Christchurch
b. Aiden McLean: transferred from his role as Principal, Bollard Girls’ Home in Tāmaki Makaurau Auckland to Assistant Principal (later promoted to Principal), Holdsworth School in Whanganui
c. Derek Tucker: transferred from his role as Senior Residential Social Worker, Bollard Girls’ Home in Tāmaki Makaurau Auckland to a similar position at Ōwairaka Boys’ Home in Tāmaki Makaurau Auckland
d. Joe Bartle: transferred from his role as Senior Housemaster, Epuni Boys’ Home in Te Awa Kairangi ki Tai Lower Hutt to Assistant Principal, Beck House in Eskdale, Te Matau-a-Māui Hawkes Bay.

396. In relation to the Marist Brothers, Brother Peter Horide acknowledged how the practice of simply shifting abusers contributed to abuse:

“To our deep regret and shame, we now realise that this system was vulnerable to exploitation by abusers and those who sought to cover up their abuse. The system of moving Brothers regularly around the country meant that it was not unusual for Brothers to spend as few as two or three years in any location. This system would allow an abuser to move around Aotearoa New Zealand undetected, continuing their abuse and avoiding their actions being reported. It also allowed members of the Brothers' leadership to move a Brother subject to complaints rather than deal with the conduct. This meant that abusers were not stopped when they should have been and people were abused when this abuse was avoidable.”[519]

397. Cardinal John Dew conceded that the Catholic Church in Aotearoa New Zealand transferred perpetrators in response to abuse allegations. He reported that complaints of sexual abuse and sexual misconduct were not well handled from the 1950s to the 1980s and that complaints may have been ‘solved’ by [MP6] the transfer of the respondent.[520] He said the Catholic Church believed perpetrators if they said offending would not happen again.[521] He acknowledged that sometimes this meant they reoffended in the new place they were transferred to and this should never have happened.[522]

398. Reverend Peter Taylor abused children at Dilworth School (Anglican) in Tāmaki Makaurau Auckland[523] and went on to hold a full licence and a Permission to Officiate between 1979 and 1987.[524] The Archbishop Philip Richardson told the Inquiry that there were incidents or overtures of sexual abuse while Peter Taylor was licensed in parishes after he taught at Dilworth School.[525] In a joint witness statement to the Inquiry, the Reverend Philip Richardson and the Reverend Donald Tamihere said:

“The way that the Church handled Peter Taylor’s offending is an example of the failures of the Church when responding to reports of abuse. Despite knowing of the abuse he committed at Dilworth, he was not subject to a disciplinary process nor reported to the Police. Indeed, he was later given other positions. No attempt was made, either, to investigate if he had offended in the positions he held before Dilworth.”[526]

399. Dilworth accepted that had there been adequate investigations at the time, further harm could have been prevented. Dr Murray Wilton, former Headmaster of Dilworth, told the Inquiry that he accepts:

“that had the complaints about McIntosh, Wynyard, Cave, [name redacted] and Wilson been fully investigated by appropriate experts, their other abuse may well have been revealed then. And possibly the abuse perpetrated by Harlow and Browne may also have come to light as a result of investigations into abuse by these other staff.”[527]

400. Leonard Cave was forced to resign from his role as a teacher at Dilworth School following allegations of sexual abuse and was provided with a positive reference when he applied for a teaching position at St Paul’s Collegiate School (Anglican) in Kirikiriroa Hamilton.[528] He went on to perpetrate abuse at St Paul’s.[529]

401. The Inquiry also heard that there were instances where the Salvation Army moved alleged abusers between posts[530] or later rehired previously dismissed officers who went on to offend against others.[531]

Te tuku, te whakateka, te whakaiti rānei i te pāmamae, i horahia hei pare kōamuamu, i hua tonu ai te mahi tūkino
Deferral, denial or harm minimisation was also used to avoid responding to complaints, which contributed to abuse

402. Sometimes senior leaders or managers would defer dealing with a complaint until NZ Police had completed their investigation. This approach was sometimes out of caution to not interfere with a NZ Police investigation.

403. At times, the Methodist Church responded to complaints with what it describes as a “traditional legal approach”, requiring survivors to report their abuse to NZ Police before the Church would conduct its own inquiries.[532]

404. Presbyterian Support Central accepts that historically it was defensive in its approach to complaints.[533]

405. In 2002, Dr George Barton QC was appointed by Presbyterian Support Central and survivors to investigate complaints of abuse at Berhampore Home in Te Whanganui-ā-Tara Wellington. Dr Barton had assured survivors involved in the investigation that he would do his best to minimise the strain and stress for them.[534] Presbyterian Support Central accept that the way Dr Barton actually conducted the investigation was legalistic and resulted in further harm and trauma being suffered by survivors.[535]

406. In other cases, senior leaders would minimise allegations, even when these involved unlawful sexual abuse, to avoid taking any steps to respond to complaints. John Gainsford was a manager at Bramwell Booth Home, a Salvation Army Children’s Home in Temuka from 1973 to 1975. In 1972, while Gainsford was serving as an officer in Gisborne, a Salvation Army Major (who was the National Social Services Secretary) met with NZ Police to discuss three incidents involving nudity and three different children. NZ Police left the complaints with the Salvation Army to deal with as it saw fit. The Social Services Secretary Army Major subsequently decided the incidents were just “foolish” behaviour by Gainsford and recommended he receive counselling.[536] The Salvation Army ultimately received 26 complaints of historical abuse by John Gainsford, most of which it advised were received after 2003.[537]

407. John Gainsford was subsequently convicted of 26 counts of sexual offending against children, including rape, between 1973 and 1974 at Bramwell Booth Home. Had the Salvation Army taken appropriate action in 1972, and in response to subsequent complaints, later prolific sexual offending by John Gainsford could have been prevented.

408. The Salvation Army was made aware of numerous allegations of abuse from the 1950s through to the early 2000s that related to the same group of eight alleged perpetrators.[538]

409. The Gloriavale Christian Community’s leadership routinely failed to respond to reports of abuse or failed to respond adequately. From its founding until the mid-1990s, all reports of sexual or physical abuse were dealt with by founder and then-Overseeing Shepherd, Neville Cooper (Hopeful Christian), who was subsequently convicted of sexual offences, including against young people.[539]

410. In 1989, in response to historical allegations of a Methodist minister sexually abusing a young girl he was fostering, another Methodist minister, Reverend David Ansell, told his superior they did not have a legal obligation to report the abuse to NZ Police:

“Thinking over the possible legal ramifications of the church ‘knowing and not telling’, I doubt there would be any. If this girl is having counselling (for whatever reason) then I think they will work out whether there is anything to tell, and I don’t think for one moment that the church bears any responsibility to do this”.[540]

411. The Methodist minister continued to foster children despite having complaints of sexual abuse against him. At the Inquiry’s Faith-based Institutional Response Hearing, Reverend Tara Tautari agreed that the prevailing attitude “was all about protecting the reputation of the [Methodist] Church and also of powerful people in the Church, powerful people being Clergy”.[541] Reverend Tautari considered that the failure of the church to act in 1989 in response to the allegations meant that:

“… the Church was complicit in enabling this abuse to continue, that it sent a message that Clergy could behave in this way and get away with it. And that it sent a message to women that they were not safe, even in our most sacred spaces.” [542]

Ko te whakautu kōamuamu a ētahi kaimahi matua me ngā kaiwhakahaere he tohi whakatau noho tapu
Some senior leaders and managers responded to complaints with confidential settlements

412. Sometimes confidential settlements were reached, which in some cases bound the person who had made the complaint.[543] Sister Susan France, Congregational Leader of the Sisters of Mercy New Zealand, said she was aware of some parts of the Catholic Church that were “protective of its reputation and as such made efforts to keep allegations of abuse quiet.”[544]

Tērā ngā kaimahi matua, kaiwhakahaere, ngā kaimahi me ngā kaiatawhai kīhai i whāki kōamuamu
Senior leaders, managers, staff and carers failed to report complaints

413. Throughout the Inquiry period many forms of abuse and neglect were against the law. However, there was no legal or mandatory direction for leaders, managers, staff and carers in State and faith-based care settings to report to NZ Police if they suspected or knew of this unlawful behaviour happening to a person in care.

414. Without government direction on reporting unlawful behaviour, abuse and neglect to NZ Police, it was left to each State or faith-based care setting to develop its own policies and practices on reporting. In 1989, the Children, Young Persons, and Their Families Act provided in law that a person may report child abuse or suspected child abuse to a social worker or police officer and that if the disclosure was provided in good faith they would be protected from civil, criminal, or disciplinary proceedings. [545]

415. Across all State and faith-based settings, there were failures to consistently report crimes against children, young people and adults in care to NZ Police.

Kīhai i whāki kōamuamui ngā takinga whaikaha, hauora hinengaro
Failure to report complaints in disability and mental health settings

416. In disability and mental health settings, it was left to each institution to develop its own policies on reporting to NZ Police. The Inquiry heard evidence that across multiple institutions there was a reluctance by staff to involve NZ Police in complaints of abuse and neglect. For example, the Palmerston North Hospital Board Staff Dismissal Committee met in 1985 after a student nurse had struck a patient four times on the buttocks with a lavatory brush at the Kimberley Centre, a psychopaedic hospital for children with learning disabilities, near Taitoko Levin. The Committee discussed the situation with the mental health district inspector, but rather than reporting the abuse to NZ Police, it resolved that the nurse “be disciplined but not dismissed or charged with assault”.[546]

417. Pākehā survivor Alison Pascoe, who was in Kingseat Psychiatric Hospital in Karaka, reported that she was sexually assaulted by a male patient when she was 12 years old, around 1954. After she disclosed the incident to staff, there were some repercussions for the patient, but there was no police involvement. Alison told the Inquiry that staff:

“…should have called the Police. I don’t know why they didn’t. Patients had no rights.”[547]

Kīhai i whāki kōamuamu i ngā takinga toko i te ora
Failure to report complaints in social welfare settings

418. In social welfare settings, the 1970 Social Workers Manual included a reporting policy that reminded staff that it was a criminal offence to ill-treat or neglect a child or to fail to provide them with the necessaries of life. The manual said that, generally speaking, NZ Police should be advised in these cases.[548] In the 1984 manual, this wording was changed to strengthen this direction, from saying “the police should be advised” to saying “police to be advised”[549].

419. From 1995, an amendment to the Children, Young Persons, and their Families Act 1989 placed a new statutory duty on the Director-General to “develop and implement protocols for agencies (both governmental and non-governmental) and professional and occupational groups in relation to the reporting of child abuse and monitor the effectiveness of such protocols”.[550]

420. Despite having these policies in social welfare settings, staff did not always follow them. Often, survivors were not believed when they disclosed abuse, and no action was taken. In other cases, sometimes social workers believed the allegations but chose not to take it any further. Former social worker Marjory van Standuleen said that as far as she was aware, “nothing was done by the department in terms of treating the abuse as an offence”.[551]

421. There were serious failures by the State to internally investigate, and refer to NZ Police, allegations of sexual abuse against a foster parent and subsequent family home caregiver who cared for at least 100 children from 1978 to 1997.[552]

422. NZ European survivor Andrea Richmond told the Inquiry she was raped by this male caregiver several times while placed with him in 1980. At the time she did not disclose the abuse because she did not know it was wrong,[553] but later in 1988 she advised her social worker that she had been sexually abused by this caregiver when she was placed with him.[554] This conversation was recorded. However, it was decided that no subsequent action should be taken to investigate the complaint or refer it to NZ Police, as the foster family were not fostering at the time. The Ministry of Social Development acknowledged that the failure to report this to NZ Police was a serious practice failure.[555]

423. The caregivers continued to foster children until 1992, when they were appointed caregivers of a family home until 1997. Over this time multiple other girls were sexually abused.[556] At least one of these girls also reported the abuse to her social workers at the time but was not believed.[557] In 1997, the caregivers were investigated for serious allegations of neglect, [MP16] and following the investigation they voluntary resigned with no consequences. The male caregiver continued to sexually abuse girls, including his adopted daughter and grandaughter, before being later convicted of sexual offending.[558]

424. A former principal of Epuni Boys’ Home in Te Awa Kairangi ki Tai Lower Hutt said that when he found out about a night supervisor sexually abusing a boy in the early 1970s, he immediately dismissed the night supervisor. However, he did not report it to NZ Police because there were no other witnesses, despite the staff member not denying the allegation and him finding the survivor “very truthful”.[559]

425. In 1983, a social worker wrote a letter to another office, stating that a foster girl in their area had complained of repeated abuse from her foster father. The social worker said that while she was “aware of no reason to doubt her word” there was “no intention by this office to take the situation any further than to notify [the Assistant Director]”.[560]

Kīhai i whāki kōamuamu i ngā takinga mātauranga
Failure to report complaints in education settings

426. As discussed above, there were no national complaints policies during the Inquiry period for education settings, including special schools for Deaf students. It was up to individual schools whether they developed their own policies or not.

427. The Inquiry did not locate any policies from the Inquiry period on referring complaints of abuse in education settings to NZ Police. NZ European survivor Mr JS, who attended Van Asch College in Ōtautahi Christchurch, told the Inquiry he could not believe that an incident of him being stabbed and needing several stitches in about 1982 was not reported to NZ Police.[561]

428. The Ministry of Education now places a responsibility on schools to report complaints or reports of concern to NZ Police in some cases.[562]

Kīhai i whāki i ngā takinga pūnaha taurima ā-whakapono
Failure to report complaints in Faith-based care settings

429. In faith-based care settings, protocols for reporting complaints or concerns to NZ Police were generally not developed during the Inquiry period.

430. The Anglican Church had no national policy on reporting abuse to secular agencies such as NZ Police and Oranga Tamariki.[563] The Right Reverend Te Kitohi Wiremu Pikaahu (Te Pihopa o Te Tai Tokerau) said that with regard to Queen Victoria School (Anglican) for Māori girls in Tāmaki Makaurau Auckland, “[u]pon review of the material disclosed to the Royal Commission, it does not appear that any reports of abuse were referred to the NZ Police or other state agencies”.[564] The position was the same at Te Aute College (Anglican) in Te Matau-a-Māui Hawkes Bay. The Most Reverend Donald Tamihere acknowledged that he had “not seen any material to suggest that any instances of abuse were referred to the Police or other State agencies”.[565]

431. Gloriavale’s current leader, Howard Temple, acknowledged that the doctrinal text “What We Believe” has historically included information that amounted to a policy that prevented its members from reporting crimes outside its community.[566] All disclosures of abuse were to be dealt with in-house by the Gloriavale leadership[567] and within the families involved.[568] Up until the mid-1990s, then-leader Neville Cooper (Hopeful Christian) dealt with the internal discipline of abusers “in the way he thought best”.[569] Current leader Howard Temple acknowledged that as recently as 2017, the Gloriavale leadership still wanted to keep sexual offending reports in-house unless the person re-offended.[570]

432. Examples of failures by Catholic Church leaders to respond to abuse include evidence regarding the internal investigations of the Catholic Church, which found that former Bishop of Dunedin John Kavanagh should have investigated a complaint of abuse against Father Freek Schokker in 1963 but failed to do so.[571] In another case, in 1977 Brother Brian O’Donnell, the Provincial of the Order of St John of God, destroyed two anonymous letters that alleged abuse by the Prior, Brother Roger Moloney and Brother Bernard McGrath at Marylands School in Ōtautahi Christchurch, “because of the harm [they] could do”.[572]

433. The Inquiry found no evidence that the Methodist Church had adequate policies on referring criminal matters to NZ Police until 2003.[573]

434. The Salvation Army did not have policies on referring criminal matters to NZ Police, as the obligation to report abuse was placed on the complainant.[574]

He ruarua nei ngā tuhinga kōamuamu mahi tūkino
Few records were kept of complaints of abuse and neglect

435. There were many limitations on data during the Inquiry period, particularly concerning complaints. In cases where no formal documentation exists it can take longer for abuse and neglect to be exposed and for perpetrators to be held to account. Ineffective record management could result in prior complaints of abuse and/or neglect being overlooked.

436. Education, social welfare, transitional and law enforcement and health settings were subject to the record keeping requirements of the Archives Act 1957, which are detailed in Part 2 of this report.

He ruarua nei ngā tuhinga kōamuamu mahi tūkino i ngā takinga ā-Turi, whaikaha, hauora hinengaro
Deaf, disability and mental health settings 

437. Few records were kept of complaints of abuse and neglect in Deaf, disability and mental health settings. Before 1992, complaints were routinely not recorded in Deaf settings, nor were they routinely recorded in disability or mental health settings. When recorded, they were often not reflective of what had happened, and were dismissive of the abuse and/or neglect reported. There are limited records regarding complaints made to relevant professional bodies.[575]

438. The New Zealand Medical Council provided the Inquiry with several documents relating to investigations into complaints about Dr Selwyn Leeks’ abuse at the Lake Alice Child and Adolescent Unit. The Council acknowledged that though some of the other documents requested by the Inquiry did exist at some stage, they could not be found:

“There is no obvious explanation as to why these documents could not be located, and it is assumed that these documents were not retained once they were no longer current”.[576]

439. The 1983 Gallen Inquiry found that incidents and allegations of ill treatment at Oakley Hospital in Tāmaki Makaurau Auckland were not recorded on patient files. Instead, an incident book was used to record altercations on the ward, including between patients and staff. The Gallen Inquiry indicated that this was done out of a desire to protect staff from any disciplinary action that might result from an allegation of mistreatment.[577]

440. The Gallen Inquiry noted that the proper process was for complaints and violent incidents to be recorded on patient files and properly investigated, including referring matters to the official visitor as soon as possible after they occurred.[578]

Ngā takinga toko i te ora
Social welfare settings

441. Limited information on complaints was often recorded and only on individual personal files. For most of the Inquiry period, the manuals were the primary source of instruction on recording information, including complaints. In 1989, they were superseded by the Care and Protection Handbooks.

442. Though the manuals and handbooks had very detailed and thorough instructions for records management,[579] the level of detail recorded in the paper files was largely dependent on the individual social worker. There were limited case reviews and quality checks until the 1984 manual introduced a review panel. The purpose of the panel was to complete an independent review and monitor progress.[580]

443. Oranga Tamariki told the Inquiry that “[f]or a 60-year period, 1950 to 2010, information about allegations of abuse, subsequent investigation and assessment and outcomes is held on individual case files and cannot be reported without reviewing each individual case file.”[581] This made it difficult to identify patterns of abuse or prolific abusers and resulted in abusive staff being rehired and children and young people being placed with abusive foster parents.[582]

444. Before the introduction of electronic systems, individual paper files meant it was difficult to track complaints if the individual file was transferred to another district, because no records remained in the current district. In 1980, a letter addressed to the Director-General of Social Welfare from a social worker discusses an allegation of abuse by a foster child against his foster father:

“Unfortunately I have to report that there have been two incidents where similar allegations have been made against this person by European youths with whom they were fostering… Unfortunately, both of these youth’s files have been transferred to other districts and I have no means of checking on any notes made at the time of the allegations.”[583]

445. The earliest electronic case management system was the Children and Young Persons Service computer information system that operated between 1990 and 1994.[584] Different versions of this electronic case management system were used until replaced with CYRAS (the current electronic case management system) in 2000.

446. At the Inquiry’s State Institutional Response Hearing, Nicolette Dickson, the Deputy Chief Executive, Quality, Practices and Experiences at Oranga Tamariki, was questioned about the possibility of records of complaints being overlooked when transferring files between districts during the Inquiry period. She replied that before the centralised case management system (CYRAS), it was “a very real risk”.[585]

447. In the foster care context, the lack of adequate record keeping resulted in earlier allegations of abuse being overlooked, and children and young people being placed with unsafe caregivers. The department recognised the risk of this as early as 1971, when it issued an internal memorandum to all District Child Welfare Officers stating that:

“From time to time a case arises where children are placed in a foster home which has proved in the past to be unsatisfactory. This may come about either because the home has not been clearly recorded as unsatisfactory or because no check was made of the records.”[586]

Ngā takinga mātauranga
Education settings

448. The Ministry of Education told the Inquiry that documentation on the record keeping practices of the Department of Education and Education Boards was not available.[587] During the Inquiry’s State Institutional Response Hearing, Secretary for Education Iona Holsted acknowledged “that record-keeping issues, including the loss of some records has caused pain to many because their full story could not be told”.[588] She said one of the reasons that she made that acknowledgement was because “individual case notes are often not available” and when accountability for schools shifted in 1989 from school boards to the Ministry, the “transfer of records was not well done”.[589]

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

449. The Inquiry saw evidence where survivors’ complaints and statements to NZ Police were not located because they had not been recorded, because they had been destroyed, or because they were lost or thought to had been lost.[590]

450. NZ Police told the Inquiry that they have had “a progression of policies and practices related to the disposal and archiving of its public records”.[591] NZ Police’s archived records fall under over 300 agencies because each NZ Police station is allocated its own agency code.[592] Archives New Zealand’s records show that NZ Police have had a schedule of categories of records for destruction and retention since at least 1961. Documents of “historical interest” had to be stored at Archives New Zealand and it was up to the officer in charge of the district to determine what met this threshold.[593]

451. NZ Police guidance on the destruction of files from 1976 (D115) did not identify any classes of offence files that should be retained, apart from files of “historical interest”. In 1984, NZ Police Schedule 8 was introduced, which referred to specific offence codes for the first time.[594] For example, it contained instructions on the disposal of documents relating to complaints against NZ Police; these had to be “transferred to National Archives in all cases where complaints result in proceedings being heard by either the Police Tribunal or District or High Courts”.[595]

Ngā takinga pūnaha taurima ā-whakapono
Faith-based care settings

452. Many survivors tried to get copies of their records of complaints from their time in faith-based care settings, only to find they had been lost or destroyed or were sparse.

453. Before this Inquiry, the Catholic dioceses and religious institutions did not centrally hold information about abuse that has been reported to Catholic Church authorities or records of decision-making about any redress provided to survivors.[596] Without adequate formal reporting processes within Catholic institutions, and because individual reports of abuse were not believed, leaders within the Catholic Church had no understanding of the scale of abuse that was occurring.[597]

454. Some Catholic institutions, such as the Order of the Brothers of St John of God, appear to have had a practice of not making or keeping records of reports of abuse and neglect that it received about brothers or more generally. This has also meant limited records were kept regarding ethnicity and disability.[598]

455. When questioned about an investigation into a complaint of sexual abuse at Dilworth School (Anglican) in Tāmakai Makaurau Auckland, Derek Firth, a former Chair and trustee of the Dilworth School Trust Board, accepted that there are no records of the investigation because they were destroyed during a “cleanout” in 1992 or 1993.[599] Mr Firth acknowledged that the Dilworth Trust Board did not have a document retention policy in those days, and decisions about record keeping were at the discretion of the general manager.[600]

456. The Anglican Church conceded that its failures to implement record keeping policies led to inconsistent responses to abuse and neglect within the Church. [601]

457. In relation to the several records of abuse and neglect at Te Aute College in Te Matau-a-Māui Hawkes Bay, the Most Reverend Donald Tamihere noted that “there is little information available on the disciplinary action, recording and reporting carried out because of the limited material available”.[602]

458. The Most Reverend Philip Richardson and the Most Reverend Donald Tamihere told the Inquiry:

“Abuse occurred which was systematic and involved significant complicity and cover-up by key staff members of some institutions. Better controls should have been in place to protect children and vulnerable people”.[603]

459. Because it was not seen as a priority, the Methodist Church had not digitised its Methodist Children’s Homes records, resulting in many documents being destroyed in the sequence of Canterbury earthquakes that started on 4 September 2010.[604] The loss of records caused pain to survivors, who rely on these to form the basis of their identity.[605]

460. The Methodist Church accepted that due to its failure to implement record keeping policies for reports of abuse and neglect, it does not have full information about all the reports and complaints that are likely to have been made to the Church.[606]

461. In relation to The Salvation Army, there is one reported instance where it was noted that records of a meeting in 1974 between The Salvation Army leadership and John Gainsford, later a convicted child abuser, were missing.[607] On a second occasion, an independent investigator reported that a complainant said that certain records may have been removed, but it was never confirmed.[608] Colonel Gerald Walker said he accepted there had been “gaps” in its documentation, but did not know how some of these had happened, noting that current retention policies did not exist earlier.[609]

462. In relation to one Presbyterian Support entity, Presbyterian Support Otago, all records were destroyed in 2017 and 2018, except for registers of names and dates. The first report of abuse had been made to Presbyterian Support Otago several years earlier in 2004, and so it was aware there had been reports of abuse and neglect at the time the decision was made to destroy the records.[610]

463. The Plymouth Brethren Christian Church told the Inquiry that it does not record the ethnicity of members, therefore it does not record the ethnicity of anyone who reported abuse and/or neglect. The same applies for disabled people.[611]

464. When asked by the Inquiry what issues have been identified in its record keeping policies and practice relating to reports of abuse, Gloriavale Christian Community responded that record keeping policies will be reviewed shortly.[612]

Kāhore te Tiriti o Waitangi i kitea i ngā kaupapa me ngā tikanga hautū mahi
Te Tiriti o Waitangi was absent in complaints processes

465. From 1950 to 1999, there was no legislated direction that complaints processes should give effect to the rights guaranteed to hapū and iwi in te Tiriti o Waitangi. Despite the disproportionate numbers of tamariki, rangatahi and pakeke Māori in care, complaints processes during the Inquiry period were not developed in partnership with whānau, hapū or iwi to embed tikanga and te ao Māori into complaints processes for tamariki, rangatahi and pakeke Māori.

466. The lack of culturally appropriate complaints processes for tamariki, rangatahi and pakeke Māori throughout the Inquiry period demonstrates a lack of concern for, and a failure of the State to actively protect, Māori in care.

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

467. The State learned that State and faith-based care settings needed detailed direction on processes for raising and responding to concerns or complaints and for record-keeping. The State introduced changes for children and young people in the care of social welfare residences in 1986, and for people subject to compulsory mental health assessment or treatment orders in 1996. All other settings were generally left to develop their own approaches to complaints processes.