468. Robust and independent oversight and monitoring is a critical way of ensuring that care providers fulfil their duties to people in their care, including detecting when they are not complying with applicable laws, regulations or policies, or not providing safe and quality care. Monitors’ reports and recommendations are crucial vehicles for prompting system improvement and for helping to ensure care providers are held accountable for the services they provide.

469. Inadequate or ineffective external oversight is a key risk factor that can contribute to abuse and neglect in care. Without effective external scrutiny, and in combination with other factors, the Inquiry saw how abuse and neglect became normalised and routine for many people in care.

470. Even where effective external oversight or monitoring is in place, it is crucial that decisive action is taken in response to their observations about abuse or neglect that is happening. Nearly all oversight and monitoring bodies during the Inquiry period lacked the ability to require change to prevent or respond to abuse or neglect in care.

Ngā mahi aroturuki i te wa o te Pakirehua
Oversight and monitoring during the Inquiry period

Ngā mahi aroturuki puta noa i ngā takinga pūnaha taurima
Oversight and monitoring across care settings

Te Tari o te Kaitiaki Mana Tangata
Office of the Ombudsman

471. The Office of the Ombudsman was established in 1962. The Ombudsman’s role is to help people in their interactions with government agencies, to carry out investigations, and deal with complaints.[613] During the Inquiry period the Ombudsman had broad investigative powers regarding any complaint brought to them, including the power to enter any premises occupied by any of the specified Departments or organisations (including the Department of Health, the Department of Education and the Department of Social Welfare) at any time and inspect the premises.[614]

Kōmihana Tika Tangata
The Human Rights Commission

472. The Human Rights Commission was formed in 1977 to promote human rights issues and hear from the public on human rights matters.[615] It monitors human rights under multiple international instruments and publishes its findings in reports to the United Nations.

473. The Human Rights Commission Act 1977 gave the Commission strategic monitoring functions including to promote respect and observance of human rights, to receive representations from the public on matters affecting human rights and to make public statements on matters affecting human rights. The Act did not explicitly give it investigative monitoring powers of entry or inspection[616] However, in receiving a complaint from the Auckland Committee on Racism and Discrimination (ACORD) in 1979 concerning the treatment of children in Department of Social Welfare homes, the Commission established its jurisdiction under the Act to investigate, question and report on such matters.[617] In carrying out these functions, it conducted interviews, received written submissions and visited and inspected several institutions[618]

474. In its report on this complaint published in 1982, the Commission noted that its lack of resourcing had resulted in a significant delay in responding:

“This report by the Human Rights Commission has been a long time in preparation. The major problem the Commission had was that there was no one able to work on it full-time, and as far as the Commissioners themselves were concerned it could only receive occasional attention among the other responsibilities of the Commission.”[619]

Ngā mahi aroturuki takinga ā-Turi, whaikaha, hauora hinengaro
Oversight and monitoring of Deaf, disability and mental health settings

475. The Mental Defectives Act 1911 set out the monitoring and oversight of disabled people and people experiencing mental distress. The Act provided for an Inspector-General of Mental Defectives, District Inspectors and Official Visitors as necessary.[620] These three roles represented the entire oversight and monitoring mechanism for psychopaedic and psychiatric hospitals until the establishment of the Human Rights Commission, the Children’s Commission and the Health and Disability Commission in the 1990s.

Kaimatawai Hauora Matua, kaimatawai a rohe, manuhiri okawa
Inspector-General of Health, District Inspectors and Official Visitors

476. The Inspector-General of Mental Defectives was responsible for the general administration of the Mental Defectives Act.[621] This included the provision of all public mental health and disability services as well as the oversight and monitoring of those services.

477. District inspectors were acknowledged in a 1983 policy proposal as “one of the few legislative safeguards available to patients in the mental health system.”[622] This safeguard was applied inconsistently and with little direction from the Department of Health. Phil Comber, a former district inspector of Kimberley Hospital in Taitoko Levin, explained that before the Mental Health (Compulsory Assessment and Treatment) Act 1992, the role of the district inspector was quite vague:

“…it wasn’t specified what it was you were supposed to do. You worked it out for yourself.”[623]

478. The Inquiry saw evidence that when district inspectors raised concerns these were not always taken seriously. A letter from district inspector David Bates on Tokanui Psychiatric Hospital near Te Awamutu to the Minister of Health included concerns that nothing was being done to improve conditions at Tokanui. The letter noted that:

“despite many inspection reports…there was no tangible evidence of progress with respect to provision of quality in-patient mental health care in this region”.[624]

479. Patients were not always aware of the role of district inspectors or how to access them. In 1979 the deputy director-general of health acknowledged that:

“in most cases psychiatric hospitals take no special steps to ensure that patients are aware of their right of access to the District Inspector”.[625]

480. Pākehā survivor Ms ON, who spent time at Claybury House at Kingseat Hospital in Karaka in the 1990s, explained:

“I had never considered that there were people out there whose job description included keeping us safe. I had no idea that people like the District Inspector were not expected to simply field complaints; they were supposed to be actively involved in inspecting the premises and making sure patients were not being abused”.[626]

481. At the beginning of the Inquiry period, the role of official visitors in monitoring psychiatric and psychopaedic hospitals was already well-established, having been provided for in legislation since 1846.[627]

482. Official visitors could visit any hospital in the area they were responsible for, without previous notice and as often as they thought fit,[628] but had to do so at least once every three months[629] and this increased to once a month for inpatients in 1992.[630]

483. In 1982 the Director of Mental Health described official visitors as a “community ‘watchdog’ on behalf of patients”, who had “visible independence from the hospital and public service” and provided advocacy for the patient when appropriate and acted as “a further safeguard against the dangers of institutionalization”.[631] Official visitors could escalate issues they observed in the hospital or that patients raised. They also reviewed how patient complaints were managed and provided recommendations to hospital management to improve this process.[632]

484. Official visitors’ reports highlighted issues to hospital management like neglect and inadequate facilities, including a lack of wheelchairs, people being confined to beds, a lack of privacy in the toilets, and poor-quality food.[633]

485. In 1974, following the transfer of responsibility for psychiatric hospitals from the Department of Health to hospital boards in 1972, official visitors were no longer considered necessary and the Department recommended they be discontinued. Only Sunnyside Hospital in Ōtautahi Christchurch and Lake Alice Child and Adolescent Unit in Rangitīkei continued to appoint official visitors because they still fell under the control of the Department.[634] Official visitors were then reinstated after the 1983 Gallen Inquiry found that “the presence of an official visitor who was readily available and conducted formal inspections would be a major and significant safeguard”.[635]

486. There were various issues with the effectiveness of official visitors, such as patients being unaware of their existence[636] or viewing them as part of the hospital system.[637] Hospital management sometimes took a hostile approach to official visitors’ reports and recommendations. For example, in 1986 an official visitor for Tokanui Psychiatric Hospital near Te Awamutu noted that the response to matters she raised varied:

“In some areas it is excellent, yet in others there is difficulty in making a report without provoking what appear to be unreasonable responses.”[638]

487. The lack of independence, definition and direction for both the district inspector and official visitor roles reduced the potential effectiveness of these roles and contributed to abuse in care.

Te Toihau Hauora Hauātanga
Health and Disability Commissioner

488. In 1994, the Health and Disability Commissioner Act was enacted to establish the role of an independent Health and Disability Commissioner, establish an independent advocacy service, and provide for a Code of Health and Disability Services Consumers’ Rights.[639] The Health and Disability Commission provides nationwide, government-funded, independent advocacy through the Advocacy Service[640] for consumers of health and/or disability services who want to make a complaint regarding a breach of their rights under the Code of Health and Disability Services Consumers’ Rights. The Advocacy Service was formally established as a free and independent service in 1996. This service operates through a national contract between the director of advocacy in the Health and Disability Commission’s (HDC) office (a publicly funded crown entity) and the National Advocacy Trust (the governing body). [641]

Ngā mahi aroturuki takinga toko i te ora
Oversight and monitoring of social welfare settings

489. The Child Welfare Act 1925 recognised the need to inspect institutions that were established under that Act and set out who could carry out inspections.[642]

490. Despite this, during the Inquiry period the State failed to properly monitor and oversee the care provided to children and young people in State institutions, family homes and foster homes. This included infrequent and ineffective monitoring visits by social workers and departmental inspectors, and unreliable paper-based monitoring. Until the late 1970s the State failed to ensure there was independent oversight and monitoring of their institutions and when mechanisms were introduced, their effectiveness at detecting abuse and neglect was questionable.

Aroturuki ā-tari ake
Internal monitoring

491. Internal monitoring mechanisms of residential services by the Department of Education and subsequently the Department of Social Welfare and its successors over the Inquiry period included visits by social workers and head office staff, formal visits and inspection reports by advisors, and principals’ annual reports.[643] The evidence the Inquiry received suggests that these mechanisms were focused on adherence with rules and processes, rather than focused on monitoring for issues across the system.

492. In the 1984 Social Work Manual, the Department of Social Welfare recognised “its responsibility and need to be accountable through both external and internal monitoring procedures” and encouraged its officers to welcome any means by which their methods were “evaluated, confirmed and improved”.[644]

Aroturuki apiha toko i te ora
Monitoring by social workers

493. Social workers’ visits to children and young people in social welfare care were a critical way of monitoring the standard of care they were receiving and whether there were concerns of abuse or neglect. This function was especially important for children in foster care and family homes because foster parents and family home caregivers were not subject to other forms of oversight and supervision.

494. Social workers should have been a critical lifeline to the outside world for children and young people who were being abused in social welfare care. However, the Inquiry heard from many survivors, as well as former caregivers[645] and social workers,[646] that social workers visited less frequently than departmental policy required them to,[647] and sometimes did not visit at all.[648] State documents reviewed by the Inquiry show that social workers’ caseloads were often too high to effectively manage,[649] which meant they visited children less regularly than required.[650]

495. The Inquiry also heard from some survivors who were in foster care that pre-arranged social worker visits allowed foster parents to prepare and present a positive image that didn’t accurately reflect their day-to-day experience.[651] Māori survivor Hemi McCallum (Ngāi Tahu, Ngāpuhi), who was in foster care in the early 1970s, told the Inquiry how his social worker visits were “all orchestrated”. Social workers did not speak to him alone, and his caregivers would “put on a banquet” and give him new clothes to present a false picture.[652]

496. During the Inquiry’s State Institutional Response Hearing, representatives of Oranga Tamariki accepted there were widespread failings where social workers did not monitor the children and young people in their care.[653]

Ngā kaimatawai me ngā kaitohutohu ā-tari
Departmental inspectors and advisors

497. Departmental inspectors from head office undertook inspections of State residences during the 1970s and 1980s but they lacked regularity, robustness and consistency. Inspections were conducted on notice.[654] Visits typically involved discussions with the principal, interviews with staff and teachers, inspection of the physical premises and examination of the institution’s records.[655] No inspection reports that the Inquiry saw referred to inspectors interviewing people in care to understand their experiences. Resident wellbeing and safety were not reported on as discrete topics. From the evidence the Inquiry reviewed, it was unclear whether inspection reports drove any change at head office.

498. Advisors were employed by head office to conduct detailed inspections of the operations of institutions. However, these inspections were rarely carried out due to a lack of staff. A 1982 review noted there was only one residential advisory position in head office, which did not provide the human resources required to visit institutions as frequently as necessary. The review said that the establishment of additional positions was “considered to be necessary to ensure that professional leadership and oversight of the institutions” was achieved.[656]

Rīpoata a te Tūmuaki
Principal’s annual reports

499. The Department required the principal of each institution to provide an annual report.[657] These reports were expected to “have a common format to ensure that essential points are covered, while allowing sufficient scope for Principals to express their primary concerns.”[658] In 1987 the principal of Kohitere Boys’ Training Centre in Taitoko Levin told the Director-General that compiling annual reports was a major task that was seen to be “stupid and of little real value” as they often “bore little resemblance to what actually went on in institutions”. He said that “I hope before I retire, I see a system of inspection emerge that will make me accountable for the overall programme I initiate in a residence”.[659] The Inquiry saw little evidence that annual reports were used by the Department of Social Welfare as an actual monitoring mechanism.[660]

Kōmiti tūārangi
Visiting Committees

500. From 1975 the Minister of Social Welfare could establish visiting committees to enter and inspect each of the institutions.[661] Membership consisted of people from the local community that the Minister deemed suitable.[662] Their role was to be accountable to the public[663] on whether the Department was providing children and young people in residential care with “an acceptable standard of care in suitable surroundings.”[664] During their visits, committee members could speak to any child or young person at that institution and examine their condition, and could report to the Director-General on any matter relating to their visit.[665] However, it was not until 1978 that any visiting committees were appointed.[666]

501. Visiting committees had discretion on how frequently they visited residences.[667] This resulted in varying levels of contact, and sometimes no contact at all. In 1980 it was recorded that at Holdsworth School in Whanganui, “[s]ince its setting up the visiting committee has not functioned despite many efforts by the former and present Principal”.[668] The same year the visiting committee for Fareham House in Pae-Tū-Mōkai Featherston was showing “little interest in the institution”, given that one member had visited once for lunch, and one had not visited at all.[669]

502. The role and function of visiting committees wasn’t sufficiently defined, which meant the effectiveness of their monitoring was variable. A 1982 memo from the Director-General to all principals noted that some visiting committees were keeping “a very low profile with little tangible evidence of benefit to the institution for which they were appointed.”[670] A Departmental review published that year found that in some residences, visiting committees had not managed to retain a level of interest. The review recommended legislative amendments to require a clearly defined function, and more regular visits and annual reports from visiting committees.[671]

503. Amendments to the legislation that year made the appointment of visiting committees mandatory for each institution.[672] They were required to visit at least once every three months and provide the Minister with an annual report that was made public.[673] The visiting committee had to ensure that children and young people in the institution were made aware of when their visits would take place and that they could discuss matters with any member of the committee.[674]

504. Even though these amendments strengthened the monitoring role of visiting committees, issues with consistency, quality and accessibility persisted. There was no clear reporting on how many children or young people were seen by visiting committees,[675] and the number of visits and levels of interaction depended on which visiting committee was involved. Infrequent visits were still an issue for some residences, and the principal of Kingslea Girls’ Home in Ōtautahi Christchurch said it was an “enduring frustration” that committee members had not taken their duties seriously.

505. When there were robust visiting committees, residences reported very positive experiences.[676] For instance, the visiting committee of Miramar Girls’ Home in Te Whanganui-ā-Tara Wellington were looking out for the wellbeing of residents in 1983 when they notified the Minister of Social Welfare about the poor conditions at the home in their inspection report:

“We do see the physical environment at the Home as oppressive. We are particularly concerned at the lack of recreation and ‘time out” facilities. We are concerned that the girls do not have space in both the physical and mental concept”.[677]

506. Although many survivors the Inquiry interviewed gave evidence about attempting to disclose the nature of their treatment in residential and institutional care, very few indicated that they raised their concerns with members of a visiting committee. In 1984 Mike Doolan noted that a continued concern of the visiting committees was “that they were not being approached by the children with worries or problems.”[678] He later reflected that this was probably because residents saw visiting committees as part of the institution’s administration, therefore they did not trust them and would never come to them with their problems.[679] Another factor adding to residents’ distrust was that visiting committees were often made up of ex-Department of Social Welfare staff.[680]

507. Additionally, many residents still did not know anything about visiting committees. A 1987 audit of Hamilton Boys’ Home stated that residents were not aware of the role and function of the visiting committee.[681]

508. In practice, visiting committees appear to have achieved little by way of substantive change and were an ineffective monitoring mechanism.[682] A former staff member of the Department told the Inquiry that although visiting committees could make recommendations, “they couldn’t require anything to happen”.[683] Historian Bronwyn Dalley believes that visiting committees did little to monitor residents’ welfare and failed to report on inappropriate staff conduct, asserting that they did not work properly and “stumbled along until 1987, when they were phased out”.[684] In 1988, following the publication of Puao-te-Ata-Tū, they were replaced by Institution Management Committees, which were intended to bring community involvement into the actual management of social welfare settings.[685]

509. Institution Management Committees were comprised mainly of people from the community who had “an interest in the wellbeing of children and young persons”[686] and one representative from the Department.[687] They were appointed by the Minister of Social Welfare to manage and direct the policy for running the institution and ensure that young people received good care and that their social and cultural needs were met while they lived at the institution. To do this the Committee kept in close contact with the institution and reviewed its programmes. Residents could ask to talk to Committee members about any concerns they had.[688]

Kaikōmihana mō ngā Tamariki
Commissioner for Children

510. The Commissioner for Children was established as an independent statutory body in 1989.[689] One of its functions was to assess and monitor the policies and practices of the State care system.[690] However, there were restrictions regarding their ability to monitor, including the Commissioner being unable to make adverse comments unless the opportunity to be heard was given.[691]

511. The Office of the Children’s Commissioner told the Inquiry that since its inception “it has been chronically underfunded to carry out its monitoring role.”[692] As a result, over the years each of the seven consecutive Commissioners have had to be very selective about what and how they monitor. This has limited their ability to effectively monitor the care and treatment of children and young people in care.[693]

Ngā mahi aroturuki takinga taiohi ā-ture
Monitoring and oversight of youth justice settings

512. Youth justice settings, like borstals and corrective training institutions, were governed by the same laws[694] and regulations[695] that applied to adult prisons. Penal institutions were the responsibility of the Department of Justice’s Penal Division until it was disestablished in 1995 and the Department of Corrections took over the role.[696]

513. Responsibility for providing monitoring and oversight of people in youth justice care sat with the Inspector of Penal Institutions and Visiting Justices. Both had discretion regarding how often they visited penal institutions.[697] From evidence reviewed by the Inquiry it appears that the time between the Inspector of Penal Institution's visits ranged from about every four years[698] to eight years or more and varied for different institutions.[699]

514. During their visits the Inspector of Penal Institutions looked at things like numbers in the prison, staffing, staff training, supervision, food and facilities.[700] While Inspectors’ reports didn’t have a specific section on inmate wellbeing, they did identify issues like overcrowding[701] and unnecessarily “cold” secure environments.[702]

515. Any inmate could request to speak to the Inspector or a Visiting Justice on a one-on-one basis.[703] However, to request this the inmate had to engage with staff so the superintendent could put their name on a list.[704] Survivors consistently told the Inquiry that a ‘no narking’ culture operated in youth justice facilities.[705] Therefore, raising complaints through staff did not feel like a viable option for many survivors.

516. Survivors in youth justice settings were not always aware of these monitoring bodies. Māori and Pākehā survivor Jonathon Stevenson (Kāti Māmoe, Kāi Tahu), who was sent to Waikeria Borstal near Te Awamutu when he was 15 years old, told the Inquiry that he felt as though there was no one to complain to, because “[t]hey didn’t tell us about the Office of the Ombudsman or about the prison inspector”. He explained that if they wanted to make a complaint, they had to ask staff for a form and tell them what it was about. If they did not tell them then they were told to go away.[706]

517. Only one survivor told the Inquiry that they were seen by a visiting justice. Māori survivor Dion Waikato (Te Arawa, Tūhoe) was placed in Dunedin Prison when he was aged 16. Because he was too young to be with the adults in the mainstream prison population, he was supposed to be in the prison’s segregation wing. He said that:

“…every time a visiting justice would visit Dunedin Prison, I would be locked back down again in segregation. The visiting justice would come and see me and see that I’m sane and that I’m not going to commit suicide and then he would leave. Then the guards would come and unlock me and tell me to go back to mainstream”.[707]

518. The Minister of Justice could appoint a visiting committee for any borstal[708] of no more than seven people.[709] Visiting committees could inquire into any matter referred to them by the Secretary of Justice.[710] Evidence reviewed by the Inquiry relating to visiting committee interviews held at Arohata Borstal in Te Whanganui-ā-Tara Wellington in 1953 and 1954 indicated monthly visits,[711] where interviews could be with new inmates,[712] people who asked for an interview[713] and people involved in disciplinary proceedings.[714] Visiting committees at Arohata Borstal produced at least one annual report.[715] A 1970 report from Invercargill Borstal in Waihopai Invercargill notes that their visiting committee met bi-monthly and members took “a keen interest in the institution”.[716]

519. Evidence received by the Inquiry shows that the monitoring and oversight mechanisms in youth justice settings produced some positive recommendations to help improve conditions for inmates, but it is unclear whether these were effective in preventing, detecting and responding to abuse.

Kaitaki atawhai ā-pae tuatoru
Third-party care providers

520. From 1927 to 1989, the State was able to enter children’s homes that were administered by voluntary agencies to inspect the premises and check on the state and condition of the children and young people living there.[717] This was undertaken by inspectors within head office of the Department of Education and subsequently the Department of Social Welfare and its successors. However, these inspections were not mandatory and there was no requirement to report findings to the relevant Minister, the Secretary of Education or the Director-General of Social Welfare and their successors.[718]

521. In the late 1980s the Department of Social Welfare began to move away from the provision of institutional care for children and young people and towards using more community-based organisations to provide care for them.[719] The Children, Young Persons, and Their Families Act 1989 allowed the Director-General (and later the Chief Executive) to approve third-party care providers under section 396 of the Act.[720] Once approved, the Director-General could use section 396 providers as a placement for children or young people under the care, custody or guardianship of the Director-General.[721] This provided for the section 396 provider to provide for that child’s or young persons’s care and upbringing and have control over them.

Tari Hautū Tahua ā Hāpori o Aotearoa
The New Zealand Community Funding Agency

522. In 1992 the New Zealand Community Funding Agency was established as a business unit within the Department of Social Welfare. They were responsible for the approval, funding, oversight and monitoring of section 396 providers.[722] The Agency had to conduct annual assessments of section 396 providers (otherwise known as third-party care providers) to ensure standards were maintained and those providers could continue providing care.[723] To make sure the Agency had enough information for their assessments they were required to monitor section 396 providers regularly.[724]

523. Monitoring visits were conducted by Community Funding Agency outreach workers.[725] They had to determine whether children and young people were receiving adequate care and make sure they were not being subjected to physical, degrading or humiliating discipline.[726] While onsite, outreach workers were required to talk to staff and where appropriate the children and young people who were placed there. They also had to examine documents and casework records relating to the children and young people.[727] In situations where the Community Funding Agency had serious concerns about the provider’s ability to continue to meet the standards and keep children and young people safe, they could suspend or revoke their section 396 approval status.[728]

524. State documents reviewed by the Inquiry show failures by the Community Funding Agency to oversee and monitor third-party care providers.

525. Moerangi Treks was a “specialist youth residential rehabilitation programme in a wilderness setting”.[729] It operated from two remote locations, one near Ruatoki in the Urewera National Park and the other on the coast at Omaio.[730] Moerangi Treks was designed to provide a safe environment for socially disadvantaged male youth, based on tikanga principles.[731]

526. The programme started providing residential care for young people referred by Children and Young Persons Service offices in July 1993.[732] In August 1997 the Community Funding Agency granted Moerangi Treks section 396 approval as a Child and Family Support Service under their standards.[733] However, before this in 1995 the Children and Young Persons Service received a complaint from a young person who attended Moerangi Treks that they were subjected to serious assaults from staff and residents at the programme.[734] It is unclear whether the Community Funding Agency considered this complaint when assessing whether to grant approval for Moerangi Treks.

527. In December 1997, young people at Moerangi Treks made allegations of physical abuse and neglect.[735] The New Zealand Children and Young Persons Service conducted an investigation that found evidence that suggested physical abuse was a regular occurrence at Moerangi Treks and that the abuse was “inflicted by staff members and other clients on the programme”. Abuse included a staff member hitting a young person around the head with a gun and choking them by tying a rope around their neck.[736] The Children, Young Persons and their Families Service informed Moerangi Treks that this was a breach of Standard 11 of their Level 1 Approval, which required that “Children and young persons are not physically punished, or disciplined or treated in way that is degrading or humiliating or causes unreasonable fear or anxiety. Alternative methods of discipline are employed.”[737]

528. In May 1998, the Community Funding Agency suspended Moerangi Treks’ approval as a Child and Family Support Service under section 399 of the Act.[738] However, the operators of the programme failed to respond to the suspension, so their approval was formally revoked in December 1998.[739]

529. During the operation of Moerangi Treks it is unclear what oversight the Community Funding Agency had and whether their outreach worker conducted monitoring as required under the Standards. Mr QS, who worked for child welfare services for 28 years, told the Inquiry that he is unaware of whether the Community Funding Agency undertook any monitoring of Moerangi Treks.[740]

530. In October 1998 the Community Funding Agency approved Eastland Youth Rescue Trust (Eastland Trust) as a Child and Family Support Service. It operated from a bush camp near Omaio and was run by one of the directors of Moerangi Treks.[741] The Children, Young Persons and their Families Service were aware of the issues at Moerangi Treks and told their staff that safeguards had been put in place to minimise the risk to young people. This included the requirement that social workers contact their clients on the programme once every two weeks.[742]

531. However, the Community Funding Agency failed to provide sufficient oversight of the programme and the additional safeguarding measures did not prevent abuse from happening. A young person first complained of abuse in December 1998 and then another in January 1999.[743] After an investigation, the Community Funding Agency allowed Eastland Trust to continue operating with requirements such as having a monitoring support person to maintain regular ongoing contact with the programme and reiterating the requirement for social workers to maintain contact with their clients.[744] State documents show that staff at Eastland Trust were “not responsive to the outreach worker’s attempts to arrange meetings to monitor the implementation of the required changes”.[745]

532. In May 1999, Samoan survivor Mr VT complained that he had been “physically and sexually and otherwise ill-treated at Eastland Trust”.[746] The Department suspended Eastland Trust’s approval while the complaint was investigated,[747] but it appears that some boys remained at Eastland Trust.[748] Following the investigation the Department was not satisfied that Eastland Trust had provided or would provide “proper standards of care to children and young persons placed in its custody” and revoked their approval as a section 396 provider in October 1999.[749]

533. Debbie Power, the Chief Executive of the Ministry of Social Development, told the Inquiry she agreed there was a need for oversight when a director of Moerangi Treks who was alleged to have committed abuse was then contracted again by the State at Eastland Trust.[750]

534. The Inquiry’s investigation into Te Whakapakari Youth Programme also highlighted the failings of the Community Funding Agency in carrying out its oversight and monitoring role.

Ratonga, tamariki, rangatahi me ō rātou whanau
Children, Young Persons and their Families Service

535. The Children, Young Persons and their Families Service, a business unit with the Department of Social Welfare, was responsible for monitoring the safety and wellbeing of children and young people in their care. For example, social workers made the decision to place children and young people in the care of third-party providers and had the role of carrying out the monitoring function.

536. Social workers were required to visit their clients every four months[751] and in 1996 this increased to every two months.[752] However, some survivors told the Inquiry that they never saw or spoke to their social worker while they were in the care of third-party providers.[753] A Community Funding Agency report in 1999 noted that social worker visits at Te Whakapakari Youth Programme on Aotea Great Barrier Island were “non existent”, but some did make contact by phone.[754]

Ngā mahi aroturuki takinga mātauranga
Oversight and monitoring of education settings

537. Between 1950 and 1989, the Director of Education (and subsequently the Chief Executive of the Ministry of Education) oversaw the administration and monitoring of the primary and secondary schooling systems through the Department of Education, under the Education Acts 1914, 1964 and 1989.

538. From the beginning of the Inquiry period until 1989, inspectors of schools visited and reported on all primary and secondary schools (private and State),[755] including assessing teacher performance in State schools.[756] Inspections were carried out with few guidelines.[757] Inspectors of schools were officers of the Department of Education, attached to Education Boards. The Education Act 1964 loosened this requirement and private schools only had to be inspected at least once every three years.[758]

539. There were two types of inspections: personal inspections, which focused on individual teachers’ effectiveness to teach, and school inspections, which focused on “making sure adequate standards of teaching and effective learning were being achieved.”[759] School inspections included “ensuring the ‘sympathetic and enlightened treatment of children’.”[760] Following each inspection, inspectors were to provide a copy of their report to either the Education Board (for a public primary school), or the School Board of Governors (for a secondary school), as well as the Department of Education.[761] However, the Director of Primary Education stated in a memorandum to the District Senior Inspector of Primary Schools that despite several years of requests, district senior inspectors had not been providing head office with copies of their inspection reports on all special schools. This included schools for Deaf and disabled children, schools in Department of Social Welfare Institutions, psychiatric and psychopaedic hospitals, health camps and education services in Department of Justice institutions.[762]

540. The Tomorrow’s Schools Reforms in 1989 shifted monitoring functions for State and State-integrated schools that the Department of Education had been responsible for to a new independent regulatory agency, the Education Review Office.[763] The Education Review Office’s role is to evaluate and publicly report on the education and care of children and young people in early childhood services and schools. The majority of the Education Review Office’s reviews are regular, although occasionally they will conduct a review on a particular matter of concern or as directed by the Minister of Education.[764]

541. The Ministry of Education told the Inquiry that from 1989 it had some oversight but little direct influence on what happened day-to-day in private schools.[765] As with boards in State and State-integrated schools, the managers of private schools set the strategic direction for their schools and adopted internal policies and procedures. The boards oversaw the management of staff, finance, property, the curriculum, and administration of the school.[766]

542. The Ministry of Education acknowledged that the statutory oversight regime for private schools and residential special schools established by faith-based institutions was restricted to the concept of ‘efficiency’ (as detailed in the paragraphs below), meaning that the oversight was more focused on the adequacy of curricula, staff numbers and qualifications, and school property.[767]

543. The sole sanction available to the Ministry of Education to penalise private schools that ceased to operate efficiently was to deregister them.[768]

544. At the Inquiry’s State Institutional Response Hearing, the Ministry of Education acknowledged that historically it had less oversight of private schools than State or State-integrated schools, and this may have provided opportunities for abusers.

545. In 1997, the Education Review Office told the Secretary and Minister for Education that children in hostels were particularly vulnerable, that some hostels were unsafe with issues of illegal behaviour including sexual abuse, harassment, threatening behaviour, assault and bullying, and that the abuse suffered in hostels could have “lifelong effects on the emotional and physical well-being of students.”[769] The Education Review Office emphasised the State’s responsibility to ensure children in private schools and hostels were safe. Although the Minister had the power to regulate hostels and boarding schools, the response to the report was for the Ministry of Education to release Circular 1997/12 (The Responsibilities of Boards of Trustees for the Personal Safety of Students in Schools). It was not until 2005 that the Education (Hostels) Regulations were introduced.[770]

Ngā mahi aroturuki takinga whakatika, mauhere ā-ture
Oversight and monitoring of transitional and law enforcement settings

546. Responsibility for oversight and monitoring of children, young people and vulnerable adults that were placed in police cells, police custody, court cells and transportation on the way to, between, or out of State care facilities predominantly sat with NZ Police.

547. There were times when responsibility sat with the Department of Corrections (or its predecessor, the Department of Justice’s Penal Division). If, for example, a sentenced prisoner appeared in Court as a witness or a victim for a matter that wasn’t related to their sentence, they would be transported to Court and supervised in Court cells by Corrections staff. Responsibility for transporting prisoners from Court-remanded custody to psychiatric hospitals sat with NZ Police.[771]

548. NZ Police told the Inquiry that they have “a limited role as a care provider” because their facilities are used for “holding” people between the time that they are arrested and bailed, or when appearing in Court. NZ Police also hold children and young people for Oranga Tamariki (as well as earlier for the predecessors of Oranga Tamariki) and people experiencing mental distress pending their assessment.[772] NZ Police Youth Aid officers also had considerable interactions with children and young people through their Juvenile Crime Prevention Branch from 1957, which was renamed the Youth Aid Section in 1968.[773] Police Commissioner Andrew Coster explained that NZ Police’s duty of care starts from the time that someone comes into their custody through to the time they are handed over to another carer.[774]

549. Although placements in these settings were only meant to be for a short time, the Inquiry heard that some survivors were there for a couple of days[775] and some for a week[776] or longer.[777] These environments were not designed for long term care and the Police Commissioner explained that “the nature of Police cells and the other people who come to be in those general areas means that they will never be suitable places for young people”.[778] This unsuitability means that children, young people and vulnerable adults placed in law enforcement and transitional care are inherently vulnerable and require robust oversight and continued monitoring to ensure their safety and wellbeing is protected.

550. Monitoring of these settings was conducted internally by NZ Police, and their procedures were governed by their Manual of General Instructions.[779] It is unclear exactly what NZ Police’s internal monitoring involved.

551. Survivors told the Inquiry that while they were in NZ Police cells, they “didn’t see sunlight or go outside for two weeks”,[780] and they were kept in a “cold, concrete spit-infested cell” and the isolation affected their wellbeing.[781] Another spoke of being held in a NZ Police cell until they confessed, with no access to a lawyer, and with food withheld and being physically abused.[782]

552. The Independent Police Conduct Authority (IPCA) was established as Aotearoa New Zealand’s first Police oversight body in 1989.[783] They can receive complaints alleging any misconduct or neglect of duty by any NZ Police employee, or concerning any practice, policy or procedure of the NZ Police affecting the person making the complaint.[784] The IPCA can also initiate an investigation if satisfied that there are reasonable grounds that it’s in the public interest or if the Police Commissioner notifies them of any incident involving death or serious bodily harm.[785]

Ngā mahi aroturuki takinga pūnaha taurima ā-whakapono
Oversight and monitoring of faith-based care settings

553. During the Inquiry period, there was little oversight and monitoring of faith-based settings. The oversight requirements that did exist in legislation were often poorly enforced by the State and the faith-based institutions and had little impact on the experiences of those in care.

554. The State had a responsibility to ensure that practices in faith-based institutions – many of which were registered care and education settings receiving State funding – were appropriate. Yet State monitoring and oversight and regulation of faith-based care settings has been largely inadequate. The State delegated its care responsibilities to faith organisations without sufficiently ensuring the quality of care being provided was appropriate.

555. In children’s homes and other residential settings such as women’s homes, survivors explained they did not receive visits from social workers.[786] Institutional witnesses told the Inquiry that the State largely took a ‘hands-off’ approach after it placed children into faith-based care, trusting churches to act in the best interests of those in their care, as outlined in the examples below.

556. The Inquiry heard that although many of the children at the Berhampore Home (Presbyterian) in Te Whanganui-ā-Tara Wellington were State wards, there was nothing in the records to suggest that the Department of Social Welfare was monitoring their wellbeing. Patrick David Waite, former Chief Executive Officer of Presbyterian Support Central, told the Inquiry: [787]

“I haven’t seen any of that [evidence of Department of Social Welfare monitoring or oversight of the wellbeing of State wards at Berhampore] in the papers that I’ve looked at. There certainly was reports from the director of the home to the State agencies about the people. A lot of that was actually around collecting the money, so it wasn’t necessarily about the health.”

557. In evidence provided to the Inquiry in 2022, the Methodist Church explained there was little involvement from the State once a child was placed in the care of the Church:[788]

“…the price that is paid is always the children, they pay the price of these decisions and this type of structure and the lack of rigour when it comes to monitoring and oversight, from both the Church and the State.”

Tē kitea te Tiriti o Waitangi i ngā mahi aroturuki
Te Tiriti o Waitangi was absent in oversight and monitoring

558. In Part 6 of this report the Inquiry noted that the Crown’s obligations as te Tiriti o Waitangi partner includes monitoring the activities of institutions and auditing institutions' performance.

559. From 1950 to 1976, there was no independent oversight or monitoring of breaches of the rights guaranteed in te Tiriti o Waitangi in State care settings. From 1975, the Waitangi Tribunal had jurisdiction to enquire into claims regarding Crown acts that were inconsistent with te Tiriti o Waitangi and its principles after 1975. From 1985, this was extended to include historical claims from 1840.[789]

560. The Tribunal was led by the Chief Judge of the Māori Land Court. Edward Taihakurei Junior Durie (Rangitāne, Ngāti Kauwhata, Ngāti Raukawa) was the first Judge of Māori descent to be appointed, in 1980. He held the position until 1998 when Joseph Victor Williams (Ngāti Pūkenga, Waitaha, Tapuika) was appointed.[790]

561. There was a lack of Maōri leadership in other oversight and monitoring bodies between 1950 and 1999. The issues the Inquiry has identified with lack of robust and independent monitoring of care settings meant that the range and scale of abuse and neglect experienced by tamariki, rangatahi and pakeke Māori in care was not as visible as it could otherwise have been. It also meant that disparities in the nature and extent of abuse and neglect experienced by Māori were not revealed. This was a breach of the Crown’s obligations of active protection, equity and equal treatment, and good government. The failure in oversight and monitoring was part of the failure to adequately care for Māori, obtain and maintain adequate information or knowledge of any abuse or neglect suffered by Māori while in care, or hold abusers to account.

He akonga i kitea ngā mea panoni i hua ki ngā mahi aroturuki
Lessons identified and changes made to oversight and monitoring

562. During the Inquiry period the State learned that independent oversight was an important way of monitoring the standard of care received by children, young people and adults in care in State institutions. However, despite increasing the number of oversight and monitoring bodies, there was no single body, or combination of bodies, with the function of oversight and monitoring of all care settings.

Footnotes

[613] New Zealand Ombudsman, Complaints about government agencies, (n.d.).