232. In Part 7, the Inquiry set out its findings about the factors that caused or contributed to abuse and neglect in care during the Inquiry period. The Inquiry found that the State and some faith-based institutions made discrete changes in some settings to introduce some safeguarding against abuse and neglect, generally from the late 1980s onwards. However, the absence of a national framework to safeguard all children, young people and adults in State and faith-based care contributed to abuse and neglect during the Inquiry period.

233. This chapter responds to clause 32A of the Inquiry’s Terms of Reference, which relates to recommendations to ensure that the factors that allowed abuse to occur during the Inquiry period do not persist. As provided for in clauses 15A and 15B of its Terms of Reference, the Inquiry has considered issues and experiences after 1999 that survivors have shared, including those set out below.[122]

Ngā wheako purapura ora mai i te tau 1999
Survivors’ experiences after 1999

234. Survivors told the Inquiry about a range of issues and experiences after 1999. These highlighted issues relating to institutional environments and practices, standards and safeguarding in care settings, vetting of staff and care workers, complaints processes, and accountability for abuse and neglect.

Ngā āhuatanga me ngā tikanga o ngā whakahaerenga
Institutional environments and practices

235. Māori survivor Mr RA (Rongomaiwahine), who was first placed in a care in 2001 when he was aged 12, told the Inquiry about his experience at Weymouth youth justice residence in Tāmaki Makaurau Auckland:

“I was also excessively restrained by staff members at Weymouth. The restraints included putting me in arm locks, wrist locks, neck locks or whatever they could wrap their arm around. … I got sent to Secure a lot, where you’d be locked down for 23 hours a day.”[123]

236. NZ European survivor Mr GG, who was placed in a care and protection residence in 2019 when he was aged 11, said:

“If I swore at someone, I would be restrained, and I have seen that result in injuries. My friend’s arm snapped from being restrained.”[124]

237. Samoan survivor Sefo Ioelu, who was placed in Lighthouse Hillsborough youth justice residence in 2008 when he was aged 14, said:

“Lighthouse was like a small prison. We were stuck in its rooms most of the day, and there was only a bed and drawers in the room with bars over the windows. I was not given any type of schooling. We had to knock on the door and ask to be let out to use the bathroom.”[125]

238. Samoan survivor Mr GU, who was in Child Youth and Family (CYF) care from 2002 when he was aged 15, told the Inquiry about his experience of sexual abuse while in a family home:

“The first time the adult son [of the care givers] sexually assaulted me occurred in a room at the Family Home. He had asked me to come in there, and then locked the door behind me. He touched my penis and tried to masturbate me. After the first assault, the adult son tried to touch me, masturbate me, or make me touch him in the car, every few days.”[126]

239. The Inquiry heard evidence of the recent misuse of solitary confinement in education settings. Callum and Victoria Turnbull, whose son Rovin attended Ruru Specialist School in Waihōpai Invercargill from 2011 when he was aged 9, told the Inquiry:

“There was no light. It had a dark raw concrete floor, with ragged, frayed carpet stuck on the walls. It was an internal room, with a window at the top facing south into a hallway, so it was dark … we could not comprehend what we saw – it was barbaric. It was abuse. Suddenly, the reasons for Rovin’s behaviour became clear to us.”[127]

He huakore o ngā raupapa mahi me te noho āhuru
Inadequate standards and safeguards

240. Pākehā survivor Mr VX described his experiences of peer abuse at Korowai Manaaki youth justice residence in Tāmaki Makaurau Auckland in the early 2000s:

“I was beaten up regularly and the staff did not care what was happening … Due to inadequate supervision, I was physically assaulted by other residents every day. On one occasion I was punched and kicked around by three other residents each time. I received a black eye and a fat lip. The assaults primarily took place in the shower, courtyard, and TV room. They were a common occurrence and became part of my daily life there. … I felt like no one cared and as a result, I began to not care.”[128]

241. Māori survivor Mr RH (Ngāi Tahu), who was first placed in a family home in 2008 when he was aged 14, said:

“I do not remember being physically or sexually abused by the caregivers but they did encourage the boys to physically fight among ourselves and they would stand back and watch, clearly enjoying it. By doing this they normalised violence as a way of life and this reinforced the views I already held.”[129]

242. Māori survivor Ms QA (Ngāti Awa, Ngāpuhi) first came to the attention of Child Youth and Family Services (CYFS) when she was 9 years old in 1997 and was placed in a family home in 2001. She told the Inquiry that:

“In all the Family Homes, there were locks on the food cupboards and fridges. I felt like an intruder, like I was not welcome. It did not feel like I was living, it was like I was surviving.”[130]

243. Pākehā survivor Ms QB, who was in Child Youth and Family Services (CYFS) care between 2015 and 2017, told the Inquiry that she was assaulted by an Oranga Tamariki care giver in a family home when she was aged 15:

“My social worker had told [the care giver] when I arrived there what triggered me and this included people getting ‘in my face’ because this puts me into a fight or flight phase in my mind. Despite this (or maybe because of it) [redacted] yelled got right up in my face and yelled at me to ‘shut the fuck up’. I wanted to have a shower and [redacted] pulled me up from the floor by my clothing, pushed me into the bathroom and told me to ‘have a fuckin shower’. I fell and hit the side of my head against the bath and then she slammed the door shut on me…I rang the CYF National Call Centre to report the incident and to inform them that I was unsafe. I told them that I did not want to stay there and, after initially saying that they would come to get [another young person] and I they then phoned back and they told me to go into my bedroom, lock the door and that they would visit in the morning…The side of my head was bruised and sore afterwards.”[131]

Ngā kaimahi me ngā kaiārahi
Staff and carers

244. Māori and non-binary survivor Alex Kaspin (Ngāi Tahu), who was placed in multiple foster homes between 1989, when they were aged 1, and 2006, when they were aged 17, told the Inquiry:

“I tried to tell [my foster mother] about what [my foster father] was doing. Her response was to defend [him] and say that he will stop and that he won’t do it anymore. She said this because she was very protective of him and her situation. He didn’t stop.”[132]

245. Māori survivor Mr RA (Rongomaiwahine) told the Inquiry:

“I have no faith in Oranga Tamariki, or their approvals and background checks, I’ve always made sure my kids have stayed with whānau while in care, because I don’t have any belief Oranga Tamariki can keep my kids safe.”[133]

246. Ms VY is a Māori survivor (Ngāti Porou) who was born in 1999. In 2016, she was placed in foster care for about three months after spending time in a youth justice facility. She said that she was never visited by a social worker in this placement and thinks this is because “it was a small community, and [her foster carer] was known by the community, CYFS and the police really well, and was well-regarded”.[134]

247. NZ European Franky Lewis, a mother of disabled survivor Keegan, described the high turnover of staff supporting her son:

“Over Keegan’s life we have had several hundred staff working in its home. In the last 5 years since we moved … we have had 20 different staff. There have been 9 different staff in 2022 alone. The turnover and inconsistency is difficult for Keegan and also difficult for me and Tony. It is so hard to find well trained staff that stay in the job long term.”[135]

248. Pākehā survivor Ms QB told the Inquiry about her experience in Child Youth and Family (CYF) care:

“The social worker did not seem to have the skills, experience or resources to know what to do with me during the day so she took custody of me but did not help me in any way by building my skill base, making a plan for me or even really getting to know me.”[136]

249. Neurodivergent survivor Ihorangi Reweti Peters (Ngāti Tūwharetoa, Ngāti Tahu-Ngāti Whaoa, Ngāti Kahungunu), who was placed in foster care, family homes and care and protection residences from the age of 10 in 2015, told the Inquiry that:

“My own experience shows that Oranga Tamariki staff are not taking mental health seriously. I understand that there is no mental health or suicide prevention training among Oranga Tamariki staff and caregivers.”[137]

Ngā kōamuamu me ngā here a mahi
Complaints and accountability

250. Disabled NZ European and Māori survivor Ms TR, who was placed in foster care at age 10, told the Inquiry that:

“…when I went to the school counsellor and disclosed what had been happening, it got back to [my foster mother]. She told [my social worker] and, in my file, it says that I over exaggerated things. Nothing was ever taken seriously.”[138]

251. Scottish and Papua New Guinean survivor Jamie Henderson, who was placed in Korowai Manaaki youth justice residence in Tāmaki Makaurau Auckland and then Te Aorere in Te Papaioea Palmerston North as a teenager in the late 2010s, said:

“Complaints aren’t encouraged in any of these facilities. It felt like I couldn’t complain while I was in YJ and the boys’ homes. … I did not know how to complain at the time. I didn’t even know the names of the staff members to allow me to make a complaint.”[139]

252. Ihorangi RewetiPeters told the Inquiry that:

“From my own experiences of engaging with the New Zealand Police, there is no direct way that young people can report what has happened to us in care via the police, and it is a daunting and traumatic experience to re-tell its accounts of abuse. … Young people in care are scared to raise their concerns because they are worried that it may affect their current placement, put them in a bad position, or that they may experience further abuse and/or neglect.”[140]

253. Māori survivor Takena Taui-Stirling (Te Whānau-ā-Apanui), who was in youth justice residences from 2001, when he was aged 14 said:

“When I got my files in 2020 I didn’t know that I could make a formal complaint or seek compensation from anyone. I never have… In terms of changes I want [Child Youth and Family] to have people that children can speak to with confidence. Not be scared of the person because of what they’ve done.”[141]

254. Callum and Victoria Turnbull, whose autistic son Rovin experienced solitary confinement at Ruru Specialist School in Waihōpai Invercargill in 2011, told the Inquiry:

“It is not good enough for the CEO of MoE to say that they can’t ensure that schools are not using seclusion. They need to come up with a way that they can ensure this. From its own experience, you cannot trust ERO to monitor or even report on the use of seclusion in schools.”[142]

255. Rangatahi from Te Rōpū Kaitiaki mō ngā Teina e Haere Ake Nei told the Inquiry that:

“There needs to be system accountability of every assault, and not allow assaults to happen in the name of ‘correcting behaviour’ in placements.”[143]

“If we in care, we should be able to report what is happening straight away and get a quick response.”[144]

“We can ensure safety by actively monitoring [and] checking care givers who put up their hand to care for tamariki.”[145]

256. Survivors’ issues and experiences are echoed in independent and State-commissioned reports on care settings after 1999, which are discussed in Chapter 2.

He ture-ā-motu hei ārai, hei tohu i te hunga kei tūkinohia i ngā pūnaha taurima
National care safety regulatory system for preventing and responding to abuse in care

257. A regulatory system is a set of formal and informal rules, norms and sanctions that are intended to shape people’s behaviours and interactions to achieve particular goals or outcomes. Regulatory systems include legislation, policies, frameworks, standards, guidelines and operational practices.

258. During the Inquiry period there were multiple regulatory systems involved in providing care across social welfare, disability and mental health, education, transitional and law enforcement, and faith-based settings. These systems were inconsistent and disconnected and had significant gaps, and ultimately failed to provide a safe environment for children, young people and adults in care.

259. There was no collective leadership or single agency responsible for all care settings. There was no single regulatory framework for ensuring care settings were safe and fit for purpose. Each system operated as a silo, with individual agencies or entities responsible for their own performance and contribution. During the Inquiry period the State increasingly recognised that preventing abuse and neglect was important and put some standards and strategies in place. However, it did not address the fragmentation of systems and the lack of a single point of accountability.

260. A national care safety regulatory system is urgently needed to ensure all care settings are safe and that no children, young people or adults in State or faith-based care experience abuse and neglect. The scope of this new regulatory system is broad, which reflects the breadth of the scope of this Inquiry. Most of the recommendations in this chapter are all components of a new national care safety system.

261. The national care safety regulatory system will focus on the elements that make settings safe and fit for purpose.

Ngā wāhanga whakahaere pūnaha āhuru mōwai ā-motu
Components of a national care safety regulatory system

262. In summary, the national care safety regulatory system will include:

a. Care Safety Principles for preventing and responding to abuse and neglect in care
b. an overarching National Care Safety Strategy that applies to all State and faith-based care settings
c. a single organisation (the Care Safe Agency) responsible for system leadership and coordination, and for setting, monitoring and enforcing care safety rules, standards and guidelines, and for promotion and public awareness of care safety
d. new legislation (the Care Safety Act) and changes to existing legislation to address duplication or inconsistencies
e. a set of rules, standards and guidelines that apply to all State and faith-based care providers and all staff and care workers, including:

i. comprehensive and consistent standards of care and sanctions for non-compliance
ii. safeguarding and accreditation requirements for care providers
iii. vetting, registration and training and education requirements for all staff and care workers
iv. transparent and accessible complaints processes, including mandatory reporting requirements
v. policies and procedures that minimise and eliminate institutional environments and practices
vi. policies and procedures that empower people in care
vii. best practice data, record-keeping and information sharing requirements

f. independent oversight and monitoring across all State and faith-based care settings.

Kō wai ka noho ārai i raro i ngā whakahaere āhuru mōwai ā-motu
Who will be protected by the national care safety regulatory system?

263. The Inquiry intends that the national care safety regulatory system will ensure that care settings are safe and fit for purpose for all children, young people and adults “in care”. The Inquiry’s definition of “in care” is based on, and aligned with, the scope of its Inquiry as set out in its Terms of Reference.[146] The definition of who the regulatory system will protect will be set out in the Care Safety Act (Recommendation 45).

264. “In care” includes being in the care of the State or a faith-based entity, including direct care (where the State or a faith-based entity provides care directly), or indirect care (where individuals or entities provide care on behalf of the State or a faith-based entity). The Inquiry also intends that the national care safety regulatory system will ensure that people who are in pastoral care are safe. Pastoral care can include, for example, youth group activities, Bible study groups, Sunday school or children’s church activities, day trips and errands, pastoral or spiritual direction, mentoring, training, or visits to congregation or community members’ homes.

265. The Inquiry intends for the new national care safety regulatory system to keep children, young people and adults in State and faith-based care safe in the following current care settings:

a. care and protection settings (including people in foster care)
b. youth justice settings
c. disability settings (people receiving disability supports and services, including while living in private residences)
d. mental health settings (people receiving mental health supports and services, including as an inpatient or in the community, voluntarily or under compulsion)
e. education settings (people attending State, integrated and private primary and secondary schools, including living in boarding facilities associated with schools)
f. transitional and law enforcement settings (including people in NZ Police custody, NZ Police cells, court cells, and people moving to, between, or out of the care settings in (a)–(e) above)
g. pastoral care.

Kō wai ka meinga kia whai i ngā whakahaere āhuru mōwai ā-motu?
Who will have to comply with the national care safety regulatory system?

266. Regulatory systems have what is called “regulated populations”. This means the people and organisations that must comply with the rules, standards and guidelines in the system. The definition of the regulated population will be set out in the Care Safety Act (Recommendation 45).

267. Under the new national care safety regulatory system, the “regulated population” will include any individual, entity, non-governmental organisation or business who provides care to children, young people and adults in current care and protection, youth justice, disability, mental health, education, or transitional and law enforcement settings. It will include State and faith-based entities providing care directly, as well as individuals and organisations providing indirect care on behalf of the State or faith-based entities. This aligns with the scope of the care settings and of children, young people and adults in care as defined in the Inquiry’s Terms of Reference.[147]

268. The Inquiry intends that the faith-based institutions that were investigated and reported on will be included within the definition of the “regulated population”. These include:

a. the Catholic Church in Aotearoa New Zealand
b. the Anglican Church in Aotearoa New Zealand and Polynesia
c. the Methodist Church of New Zealand
d. the Presbyterian Church of Aotearoa New Zealand
e. the Plymouth Brethren Christian Church
f. The Salvation Army
g. Jehovah’s Witnesses
h. Gloriavale Christian Community Church.

269. The Inquiry intends that other faith-based entities in Aotearoa New Zealand will also be included in the “regulated population”.

270. The regulated population will include the organisations providing care supports and services and the people working for those organisations. In this chapter, the Inquiry uses the term “care providers” to refer to the entities providing care. The Inquiry expects care providers will include a range of entities, including non-governmental organisations, community groups, marae, hapū, iwi, Māori organisations, schools and churches. State agencies directly providing care will fall within the definition of “care providers”. Examples include Health New Zealand Te Whatu Ora, who are responsible for inpatient mental health facilities, or Oranga Tamariki, who are responsible for youth justice residences.

271. Care providers will include entities currently providing care, as well as new entities who emerge over time. As Aotearoa New Zealand moves closer to he Māra Tipu, the Inquiry would expect to see many more new care providers emerge who understand and can meet the needs and aspirations of their local communities.

272. People who work for care providers will also fall within the definition of the “regulated population”. In this chapter the Inquiry uses the term “staff and care workers”. The Inquiry intends this term to include paid staff and volunteers. Staff and care workers will include teachers, psychiatrists, nurses, NZ Police, board members, social workers, trustees, cleaners, foster parents, priests, chief executives, church leaders, orderlies, teacher aides, gardeners, personal care assistants, and anyone else who works or volunteers for a care provider.

273. The Inquiry does not intend parents (including adoptive parents) to fall within the definitions of “care provider” or “staff and care workers” under the national care safety regulatory system. The Inquiry also does not intend that the parents and siblings of disabled children, young people or adults who receive payment to care for their family members should fall within these definitions.

Ngā mātāpono hei ārai, hei tiaki i te hunga kei tūkinohia i ngā pūnaha taurima
Principles for preventing and responding to abuse and neglect in care

274. The Inquiry has developed a set of Care Safety Principles for preventing and responding to abuse and neglect in care. These principles have informed and underpinned the Inquiry’s recommendations. The Inquiry expects these principles to be used not only to guide the implementation of these recommendations, but also to guide the operation of the national care safety regulatory system, and the provision of care supports and services, in the future. These principles represent the minimum safeguards required to protect people in care.

275. The Inquiry also envisages that State and faith-based entities (including indirect care providers) that are currently involved in the care system will use these Care Safety Principles immediately. This includes government agencies and faith leaders, as well as care providers and staff and care workers.

276. The Inquiry intends that the principles will guide decision-making, the performance of functions, and the exercising of powers and duties at all levels in the organisations, from leadership through to front-line staff. There is no need to wait for the government or faith-based entities to decide on their responses to these recommendations, or the implementation of recommendations, for these principles to be used immediately.

Tūtohi 39 | Recommendation 39

The State, faith-based entities (including indirect care providers) and others involved in the care system should be guided by the following Care Safety Principles for preventing and responding to abuse and neglect when making decisions, performing functions, or exercising powers and duties in relation to the care of children, young people and adults in care:

a) Care Safety Principle 1: The care system should recognise, uphold and enhance the mana and mauri of every person in care:

i. each person in care lives free from abuse and neglect and their overall oranga (wellbeing) is supported in a holistic way
ii. care providers understand and provide for each person and their unique strengths, needs and circumstances
iii. the importance of whānau and friendships is recognised and support from family, support networks and peers is encouraged to enable people in care to be less isolated and connected to their community
iv. people in care are celebrated and nurtured.

b) Care Safety Principle 2: People in care should participate in and make decisions affecting them to the maximum extent possible and be taken seriously:

i. people in care can participate in decisions that affect their lives, with the assistance of decision-making supports and/or an independent advocate they have chosen, where required
ii. people in care can access abuse and/or neglect prevention programmes and information
iii. staff and care workers are aware of signs of abuse and/or neglect and facilitate ways for people in care to raise concerns
iv. people who are currently or have previously been in care can participate in decision-making and policy-making about the care system.

c) Care Safety Principle 3: Whānau and support networks should be involved in decision-making processes wherever possible and appropriate:

i. connections between people in care and their whānau and support networks are actively supported, and whānau and support networks can participate in decisions affecting the person in care wherever possible and appropriate
ii. care providers engage in open communication with whānau and support networks about their abuse and neglect prevention approach
iii. whānau and support networks are informed about and can have a say in organisational and system-level policy
iv. whānau, hapū, iwi and Māori can participate in decision-making processes about their mokopuna and uri.

d) Care Safety Principle 4: The State, faith-based entities (including indirect care providers) and others involved in the care system should give effect to te Tiriti o Waitangi and enable Māori to exercise tino rangatiratanga:

i. whānau, hapū, iwi and Māori exercise the right to tino rangatiratanga over kāinga and are empowered to care for their tamariki, rangatahi, pakeke Māori and whānau according to their tikanga and mātauranga
ii. the Crown actively devolves to Māori policy and investment decisions about the care system, design and delivery of supports and services for, and specific care decisions about, tamariki, rangatahi and pakeke Māori
iii. until the realisation of principle 4(ii), Māori and the Crown should collaborate on policy and investment decisions about the care system, the design and delivery supports and services for, and specific care decisions about, tamariki, rangatahi and pakeke Māori
iv. tamariki, rangatahi and pakeke Māori who are in need of care live as Māori and are connected to their whānau, hapū, iwi, whakapapa, whenua, reo and tikanga
v. wellbeing for tamariki, rangatahi and pakeke Māori is understood and supported through an ao Māori worldview, encompassing tapu, mana, mauri and wairua.

e) Care Safety Principle 5: Abuse and neglect prevention should be embedded in the leadership, governance and culture of all State and faith-based entities (and indirect care providers) involved in the care system, including government agencies, faith leaders, care providers, and staff and care workers:

i. leaders across the care system champion the prevention of abuse and neglect in care
ii. prevention of abuse and neglect is a shared responsibility at all levels of the care system
iii. governance arrangements in agencies and entities ensure implementation of measures to prevent abuse and neglect in care and there are accountabilities and obligations set at all levels
iv. risk management strategies focus on abuse and neglect prevention
v. codes of conduct set clear behavioural expectations of all staff and care workers

f) Care Safety Principle 6: Care providers should recognise, uphold and implement human rights standards and obligations and the Enabling Good Lives principles, and recognise and provide for diverse needs including the needs of Deaf, disabled people and people experiencing mental distress:

i. people in care are supported and provided accessible information so that they can understand their rights
ii. care providers have human rights standards embedded in their policies and practice
iii. care providers understand people’s diverse circumstances and respond effectively to people who are at increased risk of experiencing abuse and/or neglect
iv. Enabling Good Lives principles underpin all support for disabled people, including culturally appropriate support as determined by whānau hauā, tāngata whaikaha and tāngata whaiora, to enable and empower disabled people to live well, participate in their community without segregation or institutionalisation, and make decisions about their lives.

g) Care Safety Principle 7: Staff and care workers should be suitable and supported:

i. all stages of recruitment, including advertising and screening, emphasise the values of caring for people in care, the safety of people in care and the prevention of abuse and neglect
ii. staff and care workers have regularly updated safety checks
iii. staff and care workers receive appropriate induction and training and are aware of their responsibilities to prevent abuse and neglect, including reporting obligations
iv. staff and care workers receive appropriate training to ensure they have cultural competency
v. education programmes for staff and care workers include units focused on understanding and preventing abuse and neglect in care
vi. supervision and people management include a focus on preventing abuse and neglect

h) Care Safety Principle 8: Staff and care workers should be equipped with the knowledge, skills and awareness to keep people in care safe through continuous education and training:

i. staff and care workers receive training on the nature and signs of abuse and neglect in care
ii. staff and care workers receive training on organisational and national abuse and neglect prevention policies and practices
iii. staff and care workers are supported to develop practical skills in safeguarding children, young people and adults in care
iv. staff and care workers have the appropriate cultural knowledge.

i) Care Safety Principle 9: Processes to respond to complaints of abuse and neglect should respond appropriately to the person (e.g. child-focused or young person-focused or adult in care-focused) in a timely manner:

i. everyone in care and their whānau and support networks have access to information and decision-making supports to help them engage in complaints processes
ii. care providers have complaint handling policies that are appropriate for the people in care and that clearly outline roles and responsibilities, approaches for responding to complaints and obligations to act and report
iii. effective complaints processes are understood by people in care, staff and volunteers, and whānau and support networks; and are culturally appropriate
iv. complaints are taken seriously, responded to promptly and thoroughly, and reporting, privacy and employment law obligations are met.

j) Care Safety Principle 10: Physical and online environments should minimise the opportunity for abuse and neglect to occur:

i. risks in online and physical environments are mitigated while upholding the right to privacy and ensuring the wellbeing of people in care
ii. online environments are used in accordance with organisations’ codes of conduct.

k) Care Safety Principle 11: Standards, policy and practice should be continuously reviewed, including from time to time independently reviewed, and improved:

i. care providers regularly review standards, policy and practice to prevent and improve responses to abuse and neglect in care
ii. complaints and concerns are analysed to identify systemic issues, both within organisations and within the care system as a whole
iii. people who are currently or have previously been in care are enabled to participate in reviews of standards, policy and practice.

l) Care Safety Principle 12: Policies and procedures should document how each care provider will ensure that people in care are safe:

i. safeguarding practice is prioritised and integrated throughout the organisation
ii. policies and procedures embed safeguarding and abuse and neglect prevention measures
iii. policies and procedures are accessible and easy to understand
iv. stakeholder consultation informs the development of policies and procedures
v. leaders champion and model compliance with policies and procedures
vi. staff and care workers understand and implement the policies and procedures.

He Rautaki Āhuru Mōwai-ā-Motu
National Care Safety Strategy

277. During the Inquiry period there was no nationwide strategic approach to preventing or responding to abuse and neglect in care. The lack of long-term strategy meant that responses to abuse and neglect in care were piecemeal and reactive. During the Inquiry period, more strategic thinking began to develop but it was contained within individual care systems.

278. The Child and Youth Wellbeing Strategy 2019, while not focussed on abuse in care, sets out a framework for improving the wellbeing of all children and young people in Aotearoa New Zealand.[148] However, there is still no single strategy for preventing abuse and neglect of children, young people and adults across all care settings.

279. A National Care Safety Strategy is required to set goals, objectives and targets, to clearly explain roles, responsibilities and accountabilities of government agencies, care providers and communities, and to describe the nature and scale of the work required. The Inquiry envisages the National Care Safety Strategy would take a multigenerational approach by, for example, identifying goals, objectives and targets at 10, 25 and 50-year intervals, rather than 1–5-year intervals.

280. The Strategy will enable all government agencies, care providers and communities to work together in a coordinated and integrated manner. The Strategy should be for everyone, including children and young people, survivors of abuse and neglect of all ages, whānau, hapū, iwi, support networks and carers, communities, non-governmental organisations, indirect care providers, and State and faith-based entities. It would also support bi-partisan commitment over the long term to support and embed meaningful, fundamental change.

281. The Inquiry would expect to see the National Care Safety Strategy cover a range of work areas, including reducing and eliminating institutional environments and practices, supporting and empowering victims, survivors and whānau, prevention strategies, better abuser accountability and intervention, improving the evidence base for preventing and responding to abuse and neglect, and public awareness and education.

282. The Inquiry would also expect to see a supporting action plan that sets out the concrete actions that will contribute to achieving the Strategy. An action plan is critical to ensure transparency and monitoring of progress.

283. Consideration will need to be given to any interfaces with other strategies and whether adaptations to those strategies will be needed.

284. The Inquiry envisages that the National Care Safety Strategy will be developed by the Care Safe Agency (Recommendation 41), guided by the Care Safety Principles (Recommendation 39), and jointly developed by government and Māori in accordance with te Tiriti o Waitangi, as well as being co-designed with communities in line with implementation Recommendations 126–127.

Tūtohi 40 | Recommendation 40

A new comprehensive National Care Safety Strategy, required by law, on the prevention of and response to abuse and neglect in care should include:

a) goals, objectives and targets that consider future generations
b) clearly understood roles and responsibilities for different organisations and entities involved in the care system
c) an overview of the priority programmes of work, including:

i. supporting and empowering victims, survivors and whānau
ii. strategies to prevent abuse and neglect
iii. better abuser accountability and intervention
iv. improving the evidence base
v. awareness raising and education
vi. enhancing approaches to children, young people and adults in care with harmful sexual behaviours.

Te whakatū Tira Āhuru Mōwai Motuhake
Establishing an independent Care Safe Agency

285. Aotearoa New Zealand needs a new, independent Care Safe Agency that has the mandate and investment needed to be a visible and best-practice regulator, so that all participants in the care system know how to prevent and respond to abuse and neglect of children, young people and adults in care.

286. The establishment of a new independent Care Safe Agency is needed to:

a. provide independent leadership and coordination of the care system
b. set, monitor and enforce care safety rules, standards and guidelines, and
c. promote and increase public awareness of care safety.

Ngā mahi ā te Tira Āhuru Mōwai Motuhake
Functions of independent Care Safe Agency

287. The Care Safe Agency will act as the primary regulatory agency for the new national care safety regulatory system. Its functions will include:

a. whole of system leadership on preventing and responding to abuse and neglect in care
b. promoting and championing the Care Safety Principles (Recommendation 39)
c. developing the National Care Safety Strategy and its supporting action plan to prevent and respond to abuse and neglect in care (Recommendation 40)
d. setting, monitoring and enforcing care safety rules and standards (Recommendation 47)
e. investigating breaches of rules and standards and enforcing a range of sanctions and penalties against care providers, staff and care workers (Recommendation 47)
f. developing best-practice guidelines on a range of issues relevant to preventing and responding to abuse in care, including safeguarding policies and procedures, and complaints policies and procedures
g. investigating and reporting on complaints received directly from users of supports and services
h. collating and keeping a centralised database of complaints and outcomes of investigations from State and faith-based care providers, other providers of supports and services, professional registration bodies, and independent oversight and monitoring entities (Recommendations 67–68)
i. accrediting care providers and other providers of supports and services (Recommendation 48)
j. registering staff and care workers who are not already covered by existing professional registration regimes (Recommendation 57)
k. setting training and education guidelines and standards and developing curriculums for staff and care workers
l. workforce development and career pathways for staff and care workers (Recommendation 61)
m. leading public awareness, education and prevention initiatives (Recommendations 111–112 and 121–122)
n. undertaking research, data analysis and horizon-scanning
o. publishing data and statistics on complaints of abuse and neglect in care to promote transparency and measurability of outcomes
p. promoting a continuous improvement and learning culture in the care system, including through facilitating regular forums and communities of practice
q. advising government on preventing and responding to abuse and neglect in care, including where systemic deficiencies are identified.

288. As a part of its research, data analysis and horizon-scanning function, the Care Safe Agency will need to keep up with demographic changes, societal shifts and international developments that may affect the care system. For example, it is expected that “there will be increasing demand for health and disability services as use and complexity increases with age and increasing prevalence of impairments and comorbidities”.[149]

289. The Inquiry also expects the Care Safe Agency to establish and drive a research agenda on abuse and neglect in care, including: building evidence on the risk, extent and impact of abuse and neglect in care; more robust data; agreed key terms and definitions; met and unmet needs; and best-practice measures to prevent and respond to abuse and neglect in care.

290. In particular, it will be important for the Care Safe Agency to keep abreast of international breakthroughs in treating trauma and preventing abuse and neglect, including considering treatment models that lie outside of the Western medical model. The best practice evidence base the Care Safe Agency gathers should be used to guide the development and refinement of policies, laws, practices and guidelines relevant to abuse and neglect, including running pilots to test initiatives in an Aotearoa New Zealand context.

291. The Inquiry expects that the Care Safe Agency will undertake its functions in accordance with te Tiriti o Waitangi and in line with implementation Recommendations 126–127. For example, it will be critical that the National Care Safety Strategy and its supporting action plan are developed with Māori in a way that gives effect to te Tiriti o Waitangi and are co-designed with communities, in consultation with current care providers and government agencies currently involved in the care system. The care safety rules, standards and best practice guidelines must meet the needs of, and reflect the experiences of, survivors and people in care.

292. The Inquiry also envisages that the Care Safe Agency will be empowered to enable individuals or other agencies to carry out specific functions where appropriate. For example, it could enable mental health district inspectors or the Education Review Office (ERO) to carry out investigations on its behalf, if appropriate.

293. The Inquiry recognises that the role, functions and powers of the new independent Care Safe Agency may overlap with roles, functions and powers of existing government departments and entities involved in the care system. The Inquiry therefore recommends that the government reviews existing government departments and entities currently involved in providing and overseeing care, to identify and address overlaps, and consolidate and disestablish, where appropriate.

Te hanga ā te Tira Āhuru Mōwai Motuhake
Form of the independent Care Safe Agency

294. There are currently at least 17 different agencies responsible for developing policy and strategy for various aspects of social policy that have implications for care systems. Each agency reports to a different portfolio Minister and has different priorities and different strategies to achieve its goals.[150] The government Child and Youth Wellbeing Strategy 2019 stated that “there are too many policies that were developed and implemented in silos”.[151] Peter Hughes, Public Service Commissioner, told the Inquiry at its State Institutional Response Hearing that:

“The Public Service has not always worked together in the way that it should and has not been joined up as it should be around children, young people and their families and communities.”[152]

295. In 2023, an interdepartmental executive board was established to strengthen system collaboration for care and provide “a single point of contact for Ministers for issues affecting the care system”.[153]

296. The Inquiry considers that a new standalone independent statutory entity should be established to objectively lead and coordinate across the whole care system. It needs to be completely independent of the people (at all levels, including those involved in strategy, policy, legislation and operational policy) and organisations who have been involved in the care system to date.

297. This is because many survivors have told us they cannot trust the organisations (or their staff) associated with the abuse and neglect they suffered and find interactions with them distressing or traumatising. As set out in Part 7, senior leaders of such organisations have often deployed measures to minimise reputational risk as well as neutralise or cover over institutional abuse during the Inquiry period. In addition to being associated with abuse and neglect in care, a number of these organisations and staff have also been involved in flawed redress processes for historical abuse claims. Survivors have compared their experiences of seeking redress to the original abuse itself.[154]

298. In the Inquiry’s view an Independent Crown Entity is required, one that is not directed by a Minister of the Crown but by an independent Board. A single, independent entity would address diffusion of responsibility, reduce fragmentation, provide cohesive leadership and accountability across the care system, provide a single, trusted point of engagement for survivors, iwi, hapū and communities and provide more responsive, effective and cohesion of functions.

299. Critical to the success of the entity is ensuring that appropriate diversity and lived experience is embedded in the leadership, governance, staffing and advisory roles for the new entity (Recommendation 134).

Tūtohi 41 | Recommendation 41

The government should establish a new standalone Care Safe Agency, with an independent Board to oversee it. The Care Safe Agency should be tasked with functions that include:

a) whole of system leadership on preventing and responding to abuse and neglect in care
b) promoting and championing the Care Safety Principles (Recommendation 39)
c) leading development and implementation of a National Care Safety Strategy and a supporting action plan to prevent and respond to abuse and neglect in care (Recommendation 40)
d) setting care safety rules and standards (legislative and non-legislative) (Recommendation 47)
e) monitoring and investigating compliance with the care safety rules and standards (Recommendation 47)
f) enforcing penalties and sanctions for breaches of the care safety rules and standards (Recommendation 47)
g) developing best practice guidelines on care safety and preventing and responding to abuse and neglect in care
h) investigating and reporting on complaints received directly from users of supports and services
i) collating and keeping a centralised database of issues of concern, complaints and the outcomes of investigations from all State and faith-based entities that provide care directly or indirectly to children, young people and adults in care, from professional registration bodies, and from independent oversight and monitoring entities (Recommendations 67–68)
j) accrediting all State and faith-based entities providing care directly or indirectly to children, young people and adults in care (Recommendation 48)
k) registering staff and care workers who are not already covered by existing professional registration regimes (Recommendation 57)
l) promoting a continuous improvement and learning culture in the care system, including facilitating regular forums and communities of practice and evaluation
m) setting training and education standards and developing curriculums for staff and care workers
n) workforce development and developing career pathways for staff and care workers (Recommendation 61)
o) leading public awareness, education and prevention initiatives (Recommendations 111–112 and 121–122)
p) undertaking research, data analysis and horizon-scanning, including building evidence on the risk, extent and impact of abuse and neglect in care
q) publishing data and statistics on complaints of abuse and neglect in care to promote transparency and measurability of outcomes
r) advising government on preventing and responding to abuse and neglect in care, including where systemic deficiencies are identified.

In defining the scope and functions of the independent Care Safe Agency, the government should consider the additional points made in Chapter 3.

Tūtohi 42 | Recommendation 42

The independent Care Safe Agency should be required to report annually to a parliamentary select committee on the implementation of the Inquiry’s recommendations and its other functions.

Tūtohi 43 | Recommendation 43

Before the independent Care Safe Agency is established, the government should review the roles, functions and powers of other government agencies involved in the care system to identify and address any duplications or gaps.

Ngā tikanga me rite i mua i te whakatūnga o te Tira Āhuru Mōwai
Interim arrangements to be in place before the setting up of the Care Safe Agency

300. Given the scale, urgency and priority of the work, the Inquiry recommends interim arrangements within the State while a new entity is established and that government should commit to a timeline for implementation. It is also important that any interim arrangements gain the trust and confidence of survivors. The interim arrangements must have no connection with the former State institutions, government departments or units associated with allegations of abuse and neglect in care, or that have been (or are still) associated or responsible for defending claims in court. This is for the same reasons as those outlined in paragraphs above for the Care Safe Agency.

301. The Inquiry thinks an appropriate arrangement would be for the Care System Office that will be responsible for implementing recommendations (Recommendations 123–124) to perform the functions of the Care Safe Agency in the interim, until it is established. The form and location of the Care System Office is discussed in Recommendation 123.

Tūtohi 44 | Recommendation 44

Until the Care Safe Agency is established, as an interim measure the government should enable the new Care System Office responsible for implementing the Inquiry’s recommendations (Recommendations 123–124) to perform the functions in Recommendation 41 above, so far as is practicable.

Te whakatū Ture Āhuru Mōwai
Establishing a new Care Safety Act

302. The Inquiry considers that new legislation is needed to ensure the foundations of a new, cohesive and integrated regulatory system for care are bedded down and codified. The legislation should create duties, and strengthen and clarify accountabilities, for care providers and staff and care workers. The legislation should include sanctions and penalties such as criminal convictions and fines for organisations and individuals involved in the provision of care (from Department directors, institutional managers, and individual staff) where they fail to fulfil their duty of care.

303. The Inquiry envisages that the legislation would provide for the independent Care Safe Agency to set, monitor and enforce care safety standards, accredit care providers, and register staff and care workers.

304. The Inquiry intends that the design of the legislation (before it is introduced into Parliament) will be developed by government and Māori in accordance with te Tiriti o Waitangi, as well as being co-designed with communities in line with implementation Recommendations 126–127. A review of legislation relevant to contemporary care settings (for example the Oranga Tamariki Act 1989, the Care of Children Act 2004, the Mental Health (Compulsory Assessment and Treatment) Act 1992, and the Pae Ora (Healthy Futures) Act 2022) will be required to identify and address inconsistencies or overlaps between regulatory regimes.

Tūtohi 45 | Recommendation 45

The government should enact a new Care Safety Act and include any legislative measures required to establish a national care safety regulatory framework and to give effect to the Inquiry’s recommendations, in particular and at a minimum:

a) to embed the Care Safety Principles for preventing and responding to abuse and neglect in care (Recommendation 39)
b) to require a National Care Safety Strategy to prevent and respond to abuse and neglect in care (Recommendation 40)
c) to establish a new independent Care Safe Agency to lead and coordinate the care system, act as the regulatory agency, and promote public awareness of preventing and responding to abuse and neglect in care (Recommendation 41)
d) to create a duty of care, and strengthen and clarify the accountabilities of all State and faith-based care providers and staff and care workers (Recommendation 47)
e) to provide for the creation of care standards (Recommendation 47)
f) to provide for an accreditation scheme for care providers (Recommendation 48)
g) to provide for the professional registration of staff and care workers (including volunteers) who are not otherwise subject to a professional registration scheme (Recommendation 57)
h) to provide for penalties, sanctions and offences for State and faith-based care providers and staff and care workers who fail to comply with statutory and non-statutory standards of care (Recommendation 47)
i) to provide for mandatory reporting (Recommendation 69)
j) to provide for a comprehensive and strengthened pre-employment screening and vetting regime for all staff and care workers (Recommendation 58).

Tūtohi 46 | Recommendation 46

The government should review all legislation and regulations relating to the care of children, young people and adults in care to identify and address any inconsistencies, gaps or lack of coherence in the relevant statutory regimes.

Te waihanga raupapa āhuru mōwai whānui me ngā whiu mo te kore e hāngai
Consistent and comprehensive care safety standards and penalties for non-compliance

305. The State has failed to set and/or ensure compliance with national standards, including legislative standards across all care settings. Rather, each setting has been left to set its own standards, guided by several different pieces of legislation. This contributed to abuse and neglect in care as there were inconsistent, inadequate, and sometimes absent protections for people in care.

Te waihanga i ngā kawenga a te pūnaha taurima ā-ture
Creating a duty of care in legislation

306. In its interim report, He Purapura Ora, he Māra Tipu: From Redress to Puretumu Torowhānui, the Inquiry recommended that the Crown should create, in legislation, “a right to be free from abuse in care” and “a non-delegable duty to ensure all reasonably practicable steps are taken to protect this right, and direct liability for a failure to fulfil the duty” (Holistic Redress Recommendation 75).[155] As the Inquiry discussed in Part 8, this recommendation has not been implemented.

307. The Inquiry considers that a statutory duty of care is a critical element of the care safety regulatory system and should be provided for in the Care Safety Act. The Inquiry envisages that the Care Safe Agency would be responsible for monitoring and enforcing compliance with the statutory duty of care.

Ngā paerewa whakamaru pūnaha taurima
Care safety standards

308. During the Inquiry period there were no legislated care standards in disability, mental health or faith-based settings. While national standards were introduced in social welfare and State education settings from the 1980s, they were enforced inconsistently and at times not at all. Because of the lack of or inconsistent standards, te Tiriti o Waitangi and human rights were not at the forefront of the provision of care.

309. The Inquiry recognises the progress that has been made in introducing and updating different care standards in different care settings since 1999.

310. For example, in health and disability settings, the Health and Disability Services (Safety) Act 2001 provides for the Minister of Health to approve standards for health and disability services.[156] The 2021 Ngā Paerewa Health and Disability Services Standard is intended to apply to all health and disability providers and services.[157] In social welfare settings, two sets of care standards have been created under the Oranga Tamariki Act 1989 – residential care standards[158] and National Care Standards.[159] In education settings, minimum legislative standards are set out in the Education and Training Act 2020.[160] Hostels and boarding facilities associated with schools have standards of care set out in the Education (Hostels) Regulations 2005.[161]

311. A consistent and comprehensive set of care safety standards is needed that apply across all State and faith-based care settings. The Inquiry envisages that the development of these standards will be led by the Care Safe Agency (Recommendation 41), guided by the Care Safety Principles (Recommendation 39), and in accordance with implementation Recommendations 126–127.

312. The Care Safe Agency may consider that some of the elements of the new care safety regulatory regime it will be responsible for, including care provider accreditation, staff and care worker registration, safeguarding policies and procedures, complaints policies and procedures, and training and education, may require supporting rules or standards. The Care Safety Act should enable the Care Safe Agency to make legislated and non-legislated standards, as appropriate.

313. As there are already a mix of legislated and non-legislated standards in some State care settings, the Inquiry envisages the government will need to consider these to identify and address any repetition or inconsistencies.

Ngā whiu mo te karo tikanga
Penalties and sanctions for non-compliance

314. As a regulatory agency, the Care Safe Agency will be responsible for encouraging compliance with rules and standards through proactive measures, including information, guidance, training and education. Equally important will be taking action against those who fail in their duty of care to keep children, young people and adults in care safe, and fail to comply with legislated and non-legislated rules and standards.

315. A critical element of holding people accountable for abuse and neglect in care is the ability to enforce penalties and sanctions. The Care Safety Act needs to include a comprehensive range of meaningful penalties and sanctions for non-compliance with the care safety rules and standards, to provide a deterrent to non-compliance.

316. The Inquiry recommends that the government provides for offences in legislation as part of the range of penalties and sanctions. The Inquiry envisages that other penalties and sanctions would include monetary fines, suspension or permanent loss of accreditation for care providers (Recommendation 48), deregistration for staff and care workers (Recommendation 57) and removal from the charities register (Recommendation 49). The Inquiry envisages these could include offences like those in the Health and Safety at Work Act 2015, which include imprisonment for the most serious offences.[162]

317. These penalties, sanctions and offences would be used in response to a failure to comply with the statutory duty of care and other rules and standards and guidelines set by the Care Safe Agency. These would include, for example, failure to report substantiated complaints of abuse and neglect, care providers operating without accreditation, care providers employing staff (including volunteers) who are not registered, or failure to ensure that staff and care workers are appropriately trained.

318. The Inquiry intends that these penalties and sanctions would apply to all State and faith-based entities providing care directly or indirectly (“care providers”), as well as individuals who work for those entities, including chief executives, trustees, board members, foster parents, volunteers, clergy and lay people (“staff and care workers”).

Tūtohi 47 | Recommendation 47

The government should:

a) establish a duty of care in the Care Safety Act that applies to all State and faith-based entities providing care directly or indirectly for children, young people and adults in care, and staff and care workers
b) provide for the Care Safe Agency to set, monitor and enforce consistent and comprehensive care safety rules and standards (legislated and non-legislated)
c) provide for a range of meaningful sanctions and penalties for individuals and State and faith-based entities providing care directly or indirectly for:

i. failure to comply with the duty of care under the Care Safety Act
ii. failure to comply with care safety rules and standards

d) provide for offences, including significant monetary fines and imprisonment, for the most serious failures to comply.

He whakamana i te hunga kaitiaki me ngā tikanga noho āhuru matua
Care providers to be accredited and prioritise safeguarding

319. Many organisations providing care during the Inquiry period failed to implement and uphold appropriate standards of care when they did exist. The State failed to adequately investigate and respond to cases where organisations providing care did not comply with standards. In some cases, complaints about abuse in organisations were made, yet the organisations providing care continued to be funded and approved to operate without any action taken to address the complaints.

320. In this chapter, the Inquiry use the term “care providers” to mean all State and faith-based entities providing care directly or indirectly to children, young people and adults in care. Care providers include a range of entities, including non-governmental organisations, community groups, marae, hapū, iwi, Māori organisations, schools, churches, and State agencies directly providing care. The Inquiry intends entities that pastoral care to be included within the definition of care providers in the Care Safety Act, even if they do not provide other kinds of care supports and funded services.

321. The Inquiry does not intend for foster parents or funded family carers of disabled people to be included within the definition of care providers in the Care Safety Act. If they were included, this would require them to be accredited to legally provide care (Recommendation 48). Foster parents (but not funded family carers) will be included within the definition of staff and care workers in the Care Safety Act (Recommendation 45), which will require them to be vetted, registered and trained in order to provide care. Wraparound support should also be provided for foster carers so as to reduce the bureaucratic burden on them and lessen the risk that these additional regulatory requirements will dissuade people from becoming foster carers.

He whakamana i te hunga kaitiaki
Care providers to be accredited

322. There are now accreditation requirements for social welfare care providers through Te Kāhui Kahu. The Inquiry did not see evidence of consistent accreditation requirements for disability and mental health care providers outside of any individual contractual arrangements.

323. Based on the evidence the Inquiry has seen, there is a need to strengthen measures to ensure care providers comply with national standards and safeguarding requirements via a system of accreditation. It is critical that this system applies consistently to all care providers and addresses gaps in current accreditation schemes. The Inquiry envisages that, in the immediate and medium term, State entities currently providing direct care supports and services within the Inquiry’s care settings, will be covered by the accreditation regime. This would include, for example, Te Whatu Ora (which currently operates inpatient mental health facilities and provides inpatient mental health services) and Oranga Tamariki (which currently operates some care and protection and youth justice facilities and provides supports and services to children and young people in care).

324. The Care Safe Agency will be responsible for the accreditation regime, including identifying the requirements for entry (what the care provider must do to become accredited), maintaining accreditation, and loss of accreditation. The Inquiry expects accreditation to be dependent on a range of issues, including compliance with the rules, standards and guidelines set and monitored by the Care Safe Agency (such as having and following safeguarding and complaints policies and procedures in place, and vetting and training staff to a minimum standard). The Inquiry envisages that the Care Safe Agency would consider other matters that could result in loss of accreditation. These could include proven criminal conduct, such as a conviction for conversion practices[163] or worker exploitation,[164] or failure to comply with other relevant regulatory regimes. The Inquiry expects that care providers operating without accreditation will be heavily penalised in a manner consistent with Recommendation 47.

Tūtohi 48 | Recommendation 48

The government should:

a) create a system for the accreditation of all State and faith-based entities providing care directly or indirectly for children, young people or adults in care
b) provide in legislation that, unless a State or faith-based entity providing care directly or indirectly is accredited, it will not be allowed to operate and will be penalised in a manner consistent with Recommendation 47.

Ka murua te mana roopu mākoha mo te karo tikanga
Charities to lose registration status for non-compliance

325. During the Inquiry period, there was a lack of faith-based institutional accountability for abuse in care. This contributed to abuse being able to occur and continue.

326. There is an existing framework that can investigate and sanction serious wrongdoing by those faith-based entities with charitable status. The Charities Act 2005 sets out the grounds under which a registered charity can be removed from the register. This includes removal if “the entity has engaged in serious wrongdoing or any person has engaged with serious wrongdoing in connection with the entity”.[165]

327. Currently, the Charities Service can investigate any charity for serious wrongdoing where there is potential criminal offending or proven instances of abuse.[166] Between 2009 and 2022, the Charities Service carried out eight investigations into faith-based charities. Two of these investigations related to Gloriavale, and the other six were faith-based institutions not investigated by this Inquiry.[167] Most faith-based institutions the Inquiry examined have received tax benefits as registered charities.

328. The Care Safety Act (Recommendation 45) will include sanctions that permit or require the de-registration of a charity where abuse or neglect is proven, or where accreditation is removed in the most serious cases, rather than requiring a separate investigation into the same wrongdoing by the Charities Services.

329. In addition, the Inquiry envisages the Care Safety Act will include a requirement for charities who fall within the definition of care provider (having children, young people and adults in their care) to comply with the rules, standards and guidelines to acquire or maintain their charitable status. Failure to comply should include sanctions that permit or require the refusal of registration or the deregistration of a charity that cares for children, young people or adults in care.

Tūtohi 49 | Recommendation 49

The government should:

a) provide for the Care Safe Agency to investigate complaints or reports of abuse or neglect in the care of registered charities, rather than requiring a separate investigation into the same wrongdoing by Charities Services
b) provide for the Care Safety Act to require that registered charities that care for children, young people or adults in care must comply with care standards
c) provide for deregistration of a charity from the register as one of the available suite of sanctions for non-compliance with care standards
d) amend the Charities Act 2005 to ensure alignment with the Care Safety Act.

Ka whakapiki te hunga kaitiaki i ngā rawa me ngā tikanga whakahaumaru
Care providers to prioritise and resource safeguarding practices

330. During the Inquiry period, the failure of institutions to prioritise clear and effective safeguarding procedures contributed to abuse and neglect. Leaders failed to sufficiently resource the care system, including staff, carers, caregivers and the facilities. This made it easier for perpetrators to not only abuse but also to not be held to account.

331. Effective leadership within organisations is critical to creating an organisational culture where people in care are valued and safeguarding is embedded at all levels. Leaders and staff need to be committed to safeguarding to ensure organisations can implement safeguarding policies effectively. Clear leadership of monitoring and accountability mechanisms is needed together with robust data collection and management.

Tūtohi 50 | Recommendation 50

The leaders of all State and faith-based entities providing care directly or indirectly should ensure there is effective oversight and leadership of safeguarding at the highest level, including at governance or trustee level where applicable.

Tūtohi 51 | Recommendation 51

The leaders of all State and faith-based entities providing care directly or indirectly should ensure that safeguarding is a genuine priority for the institution, key performance indicators are in place for senior leaders, and sufficient resources are available for all aspects of safeguarding.

Tūtohi 52 | Recommendation 52

All State and faith-based entities providing care directly or indirectly should ensure they collect adequate data on abuse and neglect in care and regularly report to the governing bodies or leaders of each institution, based on that data, so they can carry out effective oversight of safeguarding.

Tūtohi 53 | Recommendation 53

The leaders of all State and faith-based entities providing care directly or indirectly should ensure staffing, remuneration and resourcing levels are sufficient to ensure the effective implementation of safeguarding policies and procedures.

Tūtohi 54 | Recommendation 54

The senior leaders of all State and faith-based entities providing care directly or indirectly to children, young people and adults should take active steps to create a positive safeguarding culture, including by:

a) designating a safeguarding lead with sufficient seniority
b) supporting the prevention, identification and disclosure of abuse and neglect
c) ensuring the entity providing care directly or indirectly complies with its health and safety obligations
d) protecting whistleblowers and those who make good-faith notifications
e) ensuring accountability for those who fail to comply with safeguarding obligations
f) prioritising and supporting training and professional development in safeguarding and in abuse and neglect in care including the topics set out in Recommendation 63
g) actively promoting a culture that values all children, young people and adults in care and addresses all forms of discrimination
h) ensuring there are sufficient resources for safeguarding
i) identifying and correcting harmful attitudes and beliefs, such as the disbelief or mistrust of complainants or racist or ableist actions and beliefs
j) ensuring there is adequate data collection and information on abuse and neglect in care, including relevant data on ethnicity and disability, to allow analysis and reporting
k) learning from any incidents and allegations
l) publicly reporting on the matters including any issues arising in relevant annual reports.

Me whakatinana ngā kaupapa me ngā tikanga tauārai
Safeguarding policies and procedures to be implemented

332. The Inquiry found many institutions had no, inadequate, or poorly implemented safeguarding procedures including training, reporting and investigation systems to prevent and respond to abuse and neglect. Many institutions providing care paid insufficient attention to preventing and detecting the abuse and neglect of children, young people and adults in care. This was particularly evident in social welfare and youth justice residences, psychiatric and psychopaedic hospitals, special schools, faith-based children’s homes and faith-based boarding schools.

333. This began to shift from the mid-1980s onwards, where the State began to make changes to legislation that embedded discrete components of safeguarding in the policies, rules, standards, and practices of most institutions operating in health, social welfare and educational settings. This was not the case for disability and mental health settings or faith-settings, where the Inquiry found little evidence of national standards until the 1990s. These also did not apply to all people in those settings.

334. Safeguarding policies and procedures must reflect Aotearoa New Zealand’s commitment to te Tiriti o Waitangi and human rights instruments. They must express how the rights of children, young people and adults in care will be upheld while simultaneously keeping them safe.

335. Children, young people, and adults in care need safeguarding before, during, and after care. Evidence shows that lack of consistent safeguarding processes increases the risk of abuse and neglect. This is consistent with other international inquiries that note a lack of, or poor, policies, rules, standards and practices to safeguard children and adults in care, and a failure to ensure these are followed, contributes to abuse and neglect.[168]

336. All State and faith-based care providers and all relevant professional registration bodies must have accessible, effective and culturally appropriate safeguarding policies and procedures in place. The Inquiry envisages that care providers will develop these policies and procedures guided by the Care Safety Principles (Recommendation 39) and any guidance or standards developed by the Care Safe Agency (Recommendation 41). The Inquiry intends that care providers’ ability to maintain accreditation status (Recommendation 48) will be dependent on having best practice safeguarding policies and processes in place and demonstrating that these are being followed.

Tūtohi 55 | Recommendation 55

All State and faith-based entities providing care directly or indirectly should have safeguarding policies and procedures in place that:

a) are consistent with the Care Safety Principles (Recommendation 39)
b) are consistent with the National Care Safety Strategy (Recommendation 40)
c) are compliant with care safety rules and standards (Recommendation 47)
d) are consistent with best practice guidelines issued by the Care Safe Agency
e) are tailored to the risks of the particular organisation and care provided
f) are clearly written
g) are published in a readily accessible format
h) give effect to te Tiriti o Waitangi
i) are culturally and linguistically appropriate
j) are responsive to the needs of children, young people and adults in care, including Māori, Pacific Peoples, Deaf, disabled people, people experiencing mental distress, and Takatāpui, Rainbow and MVPFAFF+ people
k) are regularly reviewed, including periodic external reviews
l) are audited for compliance, including periodic external audits.

Tūtohi 56 | Recommendation 56

All State and faith-based entities providing care directly or indirectly should have safeguarding policies and procedures that address, at a minimum:

a) how the entity providing care directly or indirectly will protect children, young people and adults in care from harm
b) how the entity providing care directly or indirectly will comply with the applicable standards and principles
c) how people can make complaints about abuse and neglect to the entity, the Care Safe Agency or independent monitoring entities (Recommendation 65)
d) how complaints, disclosures and incidents will be investigated and reported, including reporting to the Care Safe Agency, professional bodies or NZ Police and other authorities (Recommendation 65)
e) the protections available to whistleblowers and those making good faith notifications of abuse and neglect
f) how the entity providing care directly or indirectly will use applicable information-sharing tools
g) how the entity will publicly and regularly report on these matters.

Ngā kaimahi me ngā kaitiaki, kia tōtika, kia āta wherawherahia, me rēhita, me tautoko, kia tika te ako
Staff and care workers to be vetted, registered, and well trained

337. From 1950-1999, the Inquiry found there was widespread poor practice in relation to the recruitment, vetting, training and support of care staff, volunteers and carers. In many cases there were no or inadequate policies in place to ensure that people providing care were appropriate and well supported to provide a safe care environment to tamariki, rangatahi and adults.

338. In this chapter, the Inquiry uses the term “staff and care workers” to mean all people who work for State and faith-based entities providing care directly or indirectly to children, young people or adults in care. The Inquiry intends this definition to be broad, to include any person who may come into contact with children, young people and adults in care through working or volunteering for a care provider. This includes foster parents, teachers, religious leaders, teaching assistants, psychiatrists, social workers, doctors, nurses, NZ Police, orderlies, chief executives, gardeners, priests, board members, trustees, cleaners, cooks, personal care assistants. The Inquiry intends for clergy and lay people who work or volunteer for entities that provide pastoral care to be included within the definition of staff and care workers in the Care Safety Act, even if the entity that provides pastoral care does not provide other kinds of care supports and funded services.

339. The Inquiry does not intend for parents (including adoptive parents) to be included in the definition of staff and care workers in the Care Safety Act. If they were, then this would require parents to be vetted, registered and trained to legally provide care for their children. The current adoption process (including private adoptions) requires prospective adoptive parents to be formally assessed and approved, including NZ Police, medical and referee checks.[169] The Inquiry is aware of significant concerns held by the disabled community and Māori about current adoption laws and practices,[170] and that the Ministry of Justice is “currently undertaking work to reform Aotearoa New Zealand’s adoption laws”.[171] The recommendations in this report are not intended to affect or influence those reforms.

340. The Inquiry does not intend for funded family carers of disabled people to be included within the definition of staff and care workers in the Care Safety Act. If they were included, it would require parents and siblings to be vetted, registered and trained to legally provide care for their disabled family members. The Inquiry is aware that there has been a recent Court of Appeal decision on the employment status of funded family carers of disabled people.[172] The Inquiry does not intend these recommendations to affect or influence those matters.

Me rēhita ngā kaimahi me ngā kaiārahi
Staff and care workers must be registered

341. There were poor standards and practices relating to the registration of care workers across the different care systems during the Inquiry period. Many sectors’ workforces were professionally unregulated, and many staff did not have the values, skills, experience and training to provide safe and appropriate care to children, young people and adults in care.

342. In disability and mental health settings, the Medical Council of New Zealand was the regulatory body responsible for the registration and discipline of medical practitioners, including psychiatrists. The Medical Practitioners Act 1995 tightened restrictions on registration. The Nursing Council of New Zealand decided who could become a registered nurse. Throughout most of the Inquiry period the only restrictions outlined in the governing legislation were that the nurse had to be a certain age and “of good character and reputation”.[173]

343. Until 1989, the Department of Education registered teachers, with no requirement to vet teachers before they worked in education settings. The Teacher’s Registration Board was established in 1989. Most other staff, including social workers and non-medical staff in disability and mental health settings were professionally unregulated for the entire Inquiry period.[174]

344. Since 1999 there have been changes to professional regulation of the care workforce. Social workers were regulated under the Social Workers Registration Act 2003, with registration being voluntary until 2021 when it became mandatory.

345. There are professional registration bodies for social workers, teachers, psychiatrists, NZ Police, nurses and medical practitioners, but there are no such bodies for other people who work (or volunteer) for care providers, such as teacher aides, clergy, orderlies, chief executives, trustees, lay people, religious leaders and personal care assistants.

346. In its view it is critical to ensure all staff and care workers are covered by an appropriate registration scheme. It also provides an additional safeguard to prevent abusers from working with children, young people and adults in care. A consistent system of professional registration will also better enable the provision of specialised support, education, training and professional development opportunities to for staff to work effectively, provide safe care environments and improve career satisfaction.

347. The Inquiry therefore recommends the creation of a new professional registration scheme that covers all staff and care workers who are not already covered by an existing professional registration regime. The Care Safe Agency will be responsible for the registration scheme, including identifying the requirements for registration, maintaining registration, suspension of registration, or de-registration. The Inquiry envisages registration to be dependent on staff and care workers complying with relevant rules, standards and guidelines set and monitored by the Care Safe Agency, including being vetted and trained.

348. The Inquiry envisages that a relevant criminal conviction or substantiated complaint of abuse or neglect would prevent a person from being registered or would result in deregistration. The Care Safe Agency will need to exercise careful judgement about what criminal convictions would create a barrier for registration, so that it does not prevent people with lived experience of care from entering the care workforce. As the Inquiry has reported, the impacts of abuse and neglect in State and faith-based care mean is it much more likely that survivors will commit offences themselves and interact with the criminal justice system. Some of these offences may not automatically mean that the survivor would not be safe to provide care.

Tūtohi 57 | Recommendation 57

The government should create a system of professional registration for all staff and care workers who are not already covered by a professional standards regime. The Care Safe Agency should be empowered to establish and maintain standards of training, conduct and professional development and with the power to enforce these through fitness to practice procedures. The government should consult on the scope and nature of the professional registration system and phase in the introduction of the system.

Me mātai, me āta wherawhera ngā kaimahi me ngā kaimahi pūnaha taurima
Staff and care workers to be screened and vetted

349. Nearly all State and faith-based settings the Inquiry investigated lacked adequate vetting and safety checking processes for potential or existing employees. Safety checks of staff or carers were not a mandatory part of recruitment processes, exposing people in care to higher risk of harm.

350. Care settings that did have safety checking processes in place tended to rely on prospective employees to self-declare any criminal activity. In the absence of system-wide policies requiring vigorous and mandatory safety checking, abusers gained access to children, young people and adults in care, with some serial abusers operating across multiple settings.

351. In addition, when safety checking processes were in place within institutions, they were often inconsistently applied. If and how safety checking for employees was implemented or followed varied from setting to setting.

352. The State made some improvements to safety checking in the latter part of the Inquiry period for foster or adoptive parents and for education. NZ Police vetting was not mandatory during the Inquiry period and was limited to some settings and some individuals. From the 1980s onwards, vetting requirements were part of service contract requirements in social welfare and disability and mental health settings. The Inquiry saw limited evidence of initiatives to improve safety checking for staff and volunteers in most faith-based settings during the Inquiry period.

353. Since 1999 there have been changes to vetting requirements for care workers and volunteers. Some settings have specific statutory requirements to vet, like education settings, and others have statutory requirements depending on whether they are a government agency, or they are funded by a government agency to provide a “regulated service” – these statutory requirements are set out in the Children’s (Requirements for Safety Checks of Children’s Workers) Regulations 2015 and apply to paid staff and volunteers in certain contexts.

354. In disability and mental health settings, it is a complex mix of professional requirements for vetting, service contract requirements, and statutory requirements like the Children’s (Requirements for Safety Checks of Children’s Workers) Regulations 2015 where these apply. For example, for community residential services funded by Whaikaha, which provides 24-hour support for disabled people, the requirements for service providers to vet their staff, paid and voluntary, is set out in the Whaikaha tier two service specification.[175]

355. The Children’s Act 2014 increased staff vetting and screening processes for all people working with children and the Children’s (Requirements for Safety Checks of Children’s Workers) Regulations 2015 require all those working with children and young people in government-funded organisations to undertake safety checks that are updated every three years.

356. In its most recent report in 2023, the Independent Children’s Monitor found that:

“In its response to the Inquiry last year, Oranga Tamariki noted it was concerned by the finding that caregivers were not always assessed prior to placing tamariki and rangatahi in their care. They noted it would remedy this with urgency… There has been no evidence of change this year, however it may be too soon to see changes.”[176]

357. At the Inquiry’s State Institutional Response Hearing, Police Commissioner Andrew Coster said that:

“The Police Vetting Service deals with more than 15,000 approved agencies who collectively request more than 600,000 vets annually. The lack of a clear statutory framework for vetting creates uncertainty about what information can be considered as part of the vetting process.”[177]

358. The Inquiry has found that poor safety checking policies and practices in care settings contribute to abuse and neglect. Comprehensive pre-employment screening practices should include thorough reference checks, examining employment history and verifying identity using multiple sources.[178] Organisations should not solely rely on background checks or assume that there is no risk of abuse and neglect once a candidate has been vetted. For this reason, safety checking needs to be included within broader safeguarding policies of all entities providing care directly or indirectly.

359. In addition to safety checking, pre-employment screening should test whether potential caregivers, including foster parents and volunteers, have appropriate values and ethics to uphold the rights of people in their care. Further, they must have the capability and capacity to remain reliable, sensitive and responsive to the needs of people in care, including their ability to tolerate difficult and challenging behaviours. People in care need to develop attachment to their caregivers in order to thrive. This is particularly true for tamariki and rangatahi of all ages, as attachment is a critical part of childhood development.[179] In promoting secure attachment caregivers also need to be able to meet the cultural needs of the people they care for.

360. The ability of caregivers to build relationships and provide consistent, sensitive and responsive care profoundly affects the organisation and security of attachment with the people they care for. Attachment-informed practice (which is also culturally responsive) may require a policy and culture shift to ensure that people’s needs are appropriately met when they are cared for away from home. This is something that should be rigorously tested as part of the pre-employment process, using a range of methods including methods appropriate to a range of cultural world views, for example Māori and Pacific Peoples.

361. There needs to be a consistent and comprehensive pre-employment screening and vetting regime that applies to all staff and care workers. As described earlier in this chapter, staff and care workers includes all people working for care providers, including paid and volunteer workers, people in religious ministry and lay people. The Inquiry intends this will include foster parents, as well as extended whānau carers who are currently included in statutory vetting requirements. The Inquiry does not intend that funded family carers of disabled people would be subject to these requirements.

362. The Inquiry envisages that this comprehensive and consistent pre-employment screening and vetting regime will be enabled through the Care Safety Act. This will require a review of current statutory arrangements, including those in the Children’s Act 2014, to identify and address gaps and overlaps.

363. The United Kingdom’s Safeguarding Vulnerable Groups Act 2006 could be reviewed for learnings and relevance to the Aotearoa New Zealand context. This Act established the Vetting and Barring Scheme, which is administered by a central agency that holds criminal records (the Disclosure and Barring Service). Under this scheme, all people working with children or adults in care have a statutory requirement to undergo a vetting process. Under the Act there is a centralised children’s barred list and adults in care barred list. Certain groups (including certain employers and local authorities) must provide information about individuals to the Disclosure and Barring Service.[180]

Tūtohi 58 | Recommendation 58

The government should:

a) provide in the Care Safety Act for a comprehensive and consistent pre-employment screening and vetting regime, so that all entities seeking to engage a person to care for children, young people or adults in care (whether as an employee, contractor, volunteer or otherwise and whether in a State or faith-based institution providing care directly or indirectly context) have timely access to comprehensive information to ensure the person is safe and suitable for the relevant role
b) ensure the regime for children’s worker safety checking remains fit for purpose
c) consider whether to introduce a barring regime like that established by the Safeguarding Vulnerable Groups Act 2006 in the United Kingdom.

Tūtohi 59 | Recommendation 59

All State and faith-based entities providing care directly or indirectly to children, young people and adults in care should ensure all prospective staff, volunteers and any other person working with children, young people or adults in care (‘prospective staff’) have a satisfactory report from the applicable vetting regime and up to date registration status.

Tūtohi 60 | Recommendation 60

All State and faith-based entities providing care directly or indirectly to children, young people and adults in care should ensure their pre-employment screening checks include:

a) thorough reference checks, including asking direct questions about any concerns about the applicant’s suitability to work with children, young people or adults in care
b) employment interviews that focus on determining the applicant’s suitability to work with children, young people or adults in care
c) critically examining an applicant’s employment history and/or written application (for example to identify and seek an explanation for gaps in employment history, or to explain ambiguous responses to direct questions about criminal history)
d) verifying the applicant’s identity, education and qualifications
e) assessing the ability of caregivers, including foster parents and volunteers, to build relationships and provide consistent, sensitive and responsive care, including being able to meet the cultural needs of the people they care for.

Me manawapā, me huhua ngā kaimahi me ngā kaimahi pūnaha taurima
Valued and diverse staff and care workers

364. During the Inquiry period, the Inquiry found that quality of care was impacted by negative conditions and employment practices for staff and care workers. Poor supervision and management practices meant that staff were often left unsupported. Care settings were also understaffed, which contributed to abuse as staff were overworked, tired and under pressure which affected their ability to provide individualised care, and led to emotional, physical, and educational neglect of people in care.

365. Providing care has been and continues to be undervalued by society. Activities that involve caring for and supporting other people have often been invisible and underpaid. The Inquiry heard of the many different ways that care work was undervalued throughout its Inquiry period. For example, in Part 3, the Inquiry discussed how there was a lack of government support for whānau wishing to support disabled tamariki, rangatahi or adults within their homes, which meant disabled people were more likely to enter care. Within care settings, the fact that care work was not valued was evident in how many staff and care workers were not appropriate or appropriately trained, were under paid, experienced poor working conditions and were otherwise not supported to provide safe and therapeutic care. These factors contributed to environments in which abuse was more likely to occur.

366. In 2021, the Oranga Tamariki Ministerial Advisory Board reported that:

“We are particularly concerned about the wellbeing of care and protection staff. They carry high and complex workloads with minimal support beyond regional offices.”[181]

367. The 2020 Health and Disability System Review, in its findings about developing a valued workforce said:

“Retaining and upskilling staff will be critical, as well as attracting new workers with appropriate skills and ensuring that the workforce is delivering culturally responsive services. This is particularly relevant for home and community support services (HCSS). These services have been delivered by a semi-trained workforce with low wages, low qualification levels and poor working conditions.”[182]

368. The Inquiry wants to see a shift to care and support being recognised for the skilled, professional work that it is. The Inquiry wants to see whānau and foster carers provided with support to provide a caring whānau environment for people in care and to meet their own wellbeing needs. This will require shifts in terms of social attitudes about the value of care, as well as conditions.

369. Staff and care workers often support children, young people and adults with complex needs and challenging circumstances. The Inquiry see positive working conditions, where staff and care workers feel valued, have support, are not overworked and under resourced and can maintain a healthy work life balance as a key way to improve quality of care and prevent abuse and neglect. There is also a need to improve work and personal satisfaction for the care sector and address issues such as poor retention and burnout. Critical to this is ensuring a positive workplace culture.

370. In addition, during the Inquiry period many staff and caregivers were not representative of people in care, particularly in leadership and governance roles. Most were Pākehā, hearing and non-disabled. This lack of diversity and lived experience contributed to a lack of understanding of the experiences of people in care and in some cases contributed to, and created, discriminatory environments.

371. In his evidence to the Inquiry, Public Service Commissioner Peter Hughes said:

“The Public Service workforce has not reflected the make-up of its society and it has not fostered workplaces that are inclusive of all groups. In my view, if you are looking for an antidote to bias and prejudice in organisations or in institutions, it is diverse and inclusive workforces.”[183]

372. A more systemic and consistent approach to increase the diversity and representation of both employers and carers is required. This includes ensuring there are career pathways and support for people with lived experience of care and from diverse backgrounds, including prioritisation of peer support networks. People with care experience bring significant value, knowledge and understanding but may require additional support. An example may be additional support for people with low literacy or accommodations for disabled or neurodivergent people to ensure they can participate in the workforce.

373. The Inquiry envisages that a part of the role of the Care Safe Agency (Recommendation 41) will be to develop a workforce strategy that addresses these issues.

Tūtohi 61 | Recommendation 61

The Care Safe Agency should develop a workforce strategy for the care sector that includes:

a) ensuring there are enough people with the right skills, experiences and values to meet needs of people in care including developing strategies to address skill gaps
b) identifying training needs
c) fostering positive workplace cultures where people in care and staff and care workers are valued and have their voices heard
d) strengthening support, supervision and management practices
e) improving workplace conditions including wellbeing, safe ratios, workloads and remuneration
f) removing barriers to enter into the care workforce in a safe manner
g) ensuring opportunities for professional development and career progression, including targeted measures to support career pathways for:

i. people with lived experience of care
ii. Māori, Pacific Peoples, Deaf, disabled people, people who experience mental distress, and Takatāpui, Rainbow and MVPFAFF+ people
h) measuring staff and carer wellbeing and satisfaction.

Tūtohi 62 | Recommendation 62

All State and faith-based entities providing care directly or indirectly to children, young people and adults in care should recruit for and support a diverse workforce, including in leadership and governance roles, so far as practicable reflecting the care communities they serve and care for.

Te ako me te tautoko i ngā kaimahi pūnaha taurima me te hunga tūao
Training and support for care workers and volunteers

374. During the Inquiry period the Inquiry found that that many staff and volunteers across both State and faith-based settings did not have sufficient skills, experience, training and support to provide safe and appropriate care to children, young people and adults. This contributed to people in care experiencing abuse and neglect.

375. In 2021, the Oranga Tamariki Ministerial Advisory Board reported that:

“The current quality and provision of training and professional development is not at an acceptable standard. The reduction in provision of training since 2017, with the expectation that supervisors and practice leaders will primarily be the trainers, has impacted on the capacity of these professional leaders to carry out their responsibilities effectively.”[184]

376. It is critical that people providing care have access to appropriate training and support to contribute to positive outcomes for people in care, building on their strengths and goals. We’ve identified key areas where training and support can be strengthened. These are in relation to safeguarding policies and procedures, recognising abuse and neglect, meeting the needs of people in care and addressing prejudice and discrimination.

377. The Care Safe Agency (Recommendation 41) will have a role in setting minimum training requirements and standard curriculum and may engage with professional registration schemes to link completion of certain training to registration and accreditation.

Ngā pouhere mahi me te ako kaimahi hei tauārai i ngā kaupapa me ngā tikanga
Staff codes of conduct and training in safeguarding policies and procedures

378. The Inquiry has made a range of recommendations about care settings instituting safeguarding policies to better protect people in care. These focus on developing safeguarding policies that are consistent with the National Care Safety Strategy (Recommendation 40) and Care Safety Principles (Recommendation 39) and ensuring appropriate leadership and resourcing for the implementation of safeguarding policies (Recommendations 55–56).

379. Another key component of having effective safeguarding policies in place is having codes of conduct in place and providing training for staff and volunteers so they understand the policies, the organisational culture prioritising safeguarding that underpins the policies and their responsibilities to safeguard people in care.

Me ako, me tautoko, hei tohi, hei ārai i ngā mahi tūkino
Training and support to identify and prevent abuse and neglect

380. The Inquiry saw that, in many cases, individuals failed to intervene to prevent abuse, despite warning signs that should have alerted them to the fact that children, young people and adults were being abused. In its view, training about how to prevent, identify and respond to abuse and neglect, is an important tool in raising understanding that abuse prevention is everyone’s responsibility.

381. Many settings did not provide adequate training and the training that was provided did not focus on creating a supportive care environment and preventing abuse and neglect. This led to the over-use of restrictive practices and solitary confinement and higher risks of harm to people in care.

382. During the Inquiry period, faith-based institutions had very limited training, relying on faith instruction rather than providing tools to train and oversee religious ministry and lay volunteers.

383. From the 1980s there was increased awareness about abuse and neglect, leading to the development of handbooks, guidelines and other training materials for staff in social welfare settings. However, training in disability and mental health institutions and most faith-based care remained limited.

384. A 2021 report from Te Kāhui Tika Tangata Human Rights Commission into the violence and abuse of disabled people in Aotearoa New Zealand found that:

“There are no nationally mandated specialized qualifications, competency requirements, or standardized training programmes for people working in the disability and violence sectors.”[185]

385. The same report found that:

“…there are few trained services/ professionals who can respond appropriately to violence, neglect and abuse of disabled people. This situation is particularly acute for people who are non-verbal and those who require support for comprehension and decision-making.”[186]

386. All staff and care workers who work for State and faith-based care providers, providing care directly or indirectly for children, young people and adults should be trained to understand their safeguarding responsibilities, and to understand and identify abuse and neglect. This should be included in educational and qualification programmes for the care workforce and tied to staff and care worker registration (Recommendation 57).

Me ako, me tautoko ngā kaimahi ki te tutaki i ngā manako o te hunga i roto i ngā pūnaha taurima
Training and support for staff to meet the needs of people in care

387. In Part 7 the Inquiry found that poor or inadequate training and development specific to care roles was a factor that allowed abuse to occur and continue, and that many Māori, Pacific Peoples, Deaf, disabled people, and people experiencing mental distress did not have their distinct needs met in care. Many staff and carers did not have the training and development needed for their roles and the demands they faced in care settings.

388. In Mana Mokopuna’s 2021 monitoring report into te Oranga residence, they said “Staff must be appropriately trained to manage mokopuna with complex mental health needs without resorting to the use of secure as a way of managing”.[187]

389. Support, supervision, training and professional development should be provided to all caregivers, including foster parents and volunteers, on a frequent and regular basis to ensure that they are able to develop and maintain their capacity to provide reliable, sensitive and responsive care to the people they are looking after, including their ability to tolerate difficult and challenging behaviours. Training should also focus on the values and ethics needed to work appropriately support people in care, including respect and understanding of diversity and recognising people’s strengths and inherent value.

Ngā mahi ako hei tutaki i ngā mahi parahako ngā āhua toihara katoa
Training that responds to prejudice and all forms of discrimination

390. Society shaped attitudes about the people in care and impacted how they were treated. This included the attitudes and views of staff and carers.

391. The Inquiry found that Māori, Pacific, Deaf, disabled, Takatāpui, Rainbow, and MVPFAFF+ survivors, and survivors who experienced mental distress were targeted and faced additional trauma as a result of abuse and neglect in State and faith-based care. In many cases, staff and carers’ attitudes reflected those in broader society which were discriminatory and reflected racism, ableism, sexism, homophobic and transphobic views.

392. At the Inquiry’s State Institutional Response Hearing, the Chief Executive for Oranga Tamariki, (Chappie Te Kani), acknowledged that one of the reasons Oranga Tamariki is trying to lift cultural capability across its workforce is because personal biases still exist and could be held by some Oranga Tamariki employees.[188]

393. At the Inquiry’s Ūhia te Māramatanga Disability and Mental Health Institutional Care Hearing, expert panellist Dr Tristram Ingham (Ngāti Kahungunu, Ngāti Porou) described how the differential quality of care received “is perpetuated, in particular, by culturally unsafe models imposed on tāngata whaikaha Māori and Māori experiences of institutional racism and explicit and implicit racism within services”.[189] Recent developments in relation to social attitudes are discussed further under Recommendation 128

Tūtohi 63 | Recommendation 63

All State and faith-based entities providing care directly or indirectly to children, young people and adults in care should ensure:

a) they have a code of conduct in place, which requires those providing care to comply with applicable safeguarding policies and procedures
b) all staff, volunteers and any others (ordained and non-ordained) working with children, young people or adults in care (“staff and care workers”) receive an induction promptly after they begin their employment and are aware of their safeguarding responsibilities including reporting obligations
c) supervisors, people leaders and all staff have a safeguarding focus and receive training that ensures understanding about the Care Safety Principles (Recommendation 39), the National Care Safety Strategy (Recommendation 40), and all statutory requirements under the Care Safety Act (Recommendation 45), including care standards, accreditation and vetting
d) all staff are trained and kept up to date in applicable safeguarding policies, procedures and practices
e) all staff receive up to date training on how to identify and prevent abuse and neglect
f) all staff are trained in appropriate trauma informed practice, disability informed practice, an understanding of neurodiversity, te Tiriti o Waitangi, Māori cultural practices, Pacific and ethnic cultural practices, human rights and an understanding of abuse and neglect in care both historically and present-day
g) all staff are trained to identify and address (in themselves and others) prejudice and all forms of discrimination
h) all staff are provided with support, supervision, training and professional development on a frequent and regular basis to ensure they are able to develop and maintain their capacity to provide reliable, sensitive and responsive care to the people they are looking after
i) all staff receive appropriate professional development support, including in how to protect children, young people and adults in care from abuse and neglect and respond to disclosures, and
j) there are no adverse employment or other consequences for those making good faith notifications or disclosures of abuse and neglect.

Tūtohi 64 | Recommendation 64

All State and faith-based entities providing care directly or indirectly to children, young people and adults in care should ensure that the same rules and standards in relation to vetting, registration, training and working conditions that apply to employees apply equally to volunteers or others with equivalent access to children, young people and adults in care, in particular, faith-based entities should ensure the same rules apply to people in religious ministry and lay volunteers as to employees.

Kia tika te whakaea i ngā tautohenga
Complaints are responded to effectively

394. During the Inquiry period there was a lack of accessible, effective and culturally appropriate complaints processes in both State and faith-based institutions. Some settings, such as faith-based care, did not have any complaints processes in place to follow. Where there were complaints processes in place they could be unclear and their use highly dependent on the individual institutions and staff in charge.

395. The Inquiry heard that survivors were often not believed, and employee rights were prioritised over the rights of survivors to be heard. Institutions protected their or the abuser’s reputation over the survivor needs. The Inquiry also saw instances where abusers held positions where they had responsibility for receiving and investigating complaints. There was also a failure to report complaints to NZ Police. For the limited number that NZ Police heard about there was again a failure to believe the survivors, resulting in inadequate responses and follow up and poor record keeping of any of complaints.

396. All of these factors meant that few perpetrators received any consequences for their actions.

397. Implementing the recommendations in this report will result in four possible pathways for people who use care supports and services and their whānau and support networks to make complaints, disclosures or report incidents of abuse and neglect in care:

a. complaints to the relevant State or faith-based care provider
b. complaints to the relevant professional registration body
c. complaints to the Care Safe Agency
d. complaints to independent oversight and monitoring bodies.

398. Care providers and relevant professional registration bodies will be required to have consistent and comprehensive complaints policies and procedures (guided by the Care Safe Principles). They will also be required to hold perpetrators to account, by taking appropriate professional disciplinary action, and reporting substantiated complaints to the Care Safe Agency and NZ Police.

Me whakarite ngā kaupapa me ngā tikanga takinga kōamuamu
Complaints policies and procedures are in place

399. During the later part of the Inquiry period, more comprehensive complaints processes were introduced, for example, the Children and Young Persons (Residential Care) Regulations 1986 introduced rights to a grievance procedure (further expanded in 1996), and the Mental Health (Compulsory Assessment and Treatment) Act 1992 included a complaints procedure.

400. The Inquiry saw limited evidence of formal investigative processes within faith-based institutions during the Inquiry period. In 1998 some progress was made in the Catholic Church with the introduction of Te Houhanga – A Path to Healing, but this guidance only dealt with sexual abuse. More recently, other faith-based institutions have begun developing guidance for complaints processes.

401. A review of Disability Support Services in 2013 found a recurring theme in one of the services run by a charitable trust was the “fear of retribution if a family member or resident complained about the quality of the service.” A report from the temporary managers of the service noted that:

“The Residents are too scared to complain, because past experience has taught them that complaining could be very punishing.”[190]

402. A 2013 report on the experiences of disabled people living in the community found that disabled people faced numerous barriers to making complaints:

“In all situations where a complaint was made to the police the allegedly abused individual remained in the residence or home during the investigative period. Further, in the majority of cases there was insufficient evidence to arrest or remove the perpetrator from the residence. This placed the complainant at considerable risk of retribution.[191]

Numerous accounts were offered where a complaint of abuse was negated on the grounds that the disabled person’s testimony lacked veracity. This generally involved some form of disparagement of the individual complainant. … On other occasions the complainant’s strength of character was questioned. This was reported as most commonly occurring when individuals possessed a mental health diagnosis.”[192]

403. Issues with the way that school boards handle complaints and investigations persist. They were highlighted in the media in June 2023 in an incident involving a five-year-old boy being physically and sexually assaulted by two older pupils in the toilets of his Waikato school. The boy’s father was “astounded the two boys involved had not been immediately suspended” and believed that that the principal was not taking the “situation seriously because the parents of the alleged abusers are involved in the school community”.[193]

404. Workplace culture in care settings must enable and support people to make complaints when they want to report any concerns about abuse and neglect. There also needs to be more accountability, transparency and monitoring of responses to complaints received and how they were resolved and to see where and how improvements can continue to be made. By increasing the monitoring for complaints processes and consistently reviewing and sharing this information the Inquiry can aim to improve trust in the care system.

405. All State and faith-based care providers and all relevant professional registration bodies must have accessible, effective and culturally appropriate complaints and investigation policies and procedures in place. The Inquiry envisages that care providers will develop these policies and procedures guided by the Care Safety Principles (Recommendation 39) and any guidance or standards developed by the Care Safe Agency. The Inquiry envisages that care providers’ ability to maintain accreditation status (Recommendation 48) will be dependent on having best practice complaints policies and processes in place and demonstrating that these are being followed.

406. The relevant professional registration bodies include the Royal Australian and New Zealand College of Psychiatrists, the Medical Council of New Zealand, the Aotearoa New Zealand Association of Social Workers, the New Zealand Nurses Association and the Teaching Council of Aotearoa New Zealand.

Tūtohi 65 | Recommendation 65

All State and faith-based entities providing care directly or indirectly to children, young people and adults in care and relevant professional registration bodies should ensure they have appropriate policies and procedures in place to respond in a proportionate way to complaints, disclosures or incidents of abuse and neglect, including:

a) the policies and procedures are guided by the Care Safety Principles (Recommendation 39) and any relevant rules, standards or guidelines issued by the Care Safe Agency (Recommendation 41)
b) the policies and procedures are clearly written, accessible to people in care, their whānau and support networks, and to staff and care workers, and kept up to date
c) the policies, at a minimum, outline roles and responsibilities, how different types of complaints will be handled, including potential employment outcomes and reporting obligations
d) the policies set out how actual or perceived conflicts of interest will be addressed if they arise
e) there are clear protections in place for whistleblowers and those making good faith notifications
f) it is as easy as possible for people to make disclosures or complaints
g) complaints processes are appropriate for Māori, Pacific People, Deaf, disabled people, people who experience mental distress, and Takatāpui, Rainbow and MVPFAFF+ people, including ensuring there is access to appropriate support
h) complainants are supported and kept informed throughout the handling of their complaint, including with the assistance of their independent advocates (Recommendation 76) if applicable
i) complainants are kept safe throughout the handling of their complaint, including if they have complained about another person in care or a person who directly provides them care
j) complaints are responded to promptly and robustly, including:

i) as soon as a complaint is made, carrying out an initial risk assessment to identify the risks to the complainant and to other children, young people and adults in care
ii) mitigating identified risks while the complaint is being investigated, proportionate to the seriousness of the allegation
iii) continuing to investigate and report on complaints even if the subject of the complaint voluntarily leaves employment and/or cancels their professional registration
iv) carrying out a robust investigation at a level proportionate to the seriousness of the complaint
v) applying a standard of proof consistent with civil law (“on the balance of probabilities”) when investigating complaints, but doing so flexibly, proportionate to the seriousness of the allegation
vi) using external investigators where appropriate for the most serious allegations
vii) meeting all privacy and employment law obligations
viii) ensuring appropriate accountability, including through reporting to NZ Police and relevant professional registration bodies if the complaint is substantiated (Recommendation 66)

k) all complaints must be reported to the Care Safe Agency (Recommendation 41) regardless of the outcome of the investigation
l) each complaint must be reviewed for lessons identified and possible improvements
m) publicly report annually on how many complaints they are dealing with, whether they have been resolved, whether they have been substantiated, and how long the complaint took to be resolved.

Me whiu rawa te hunga kua tūturu ngā kōamuamu mahi tūkino
People must be held to account for substantiated complaints of abuse and neglect in care

407. During the Inquiry period, individual abusers were frequently not held accountable for abuse and neglect. The lack of appropriate complaints processes combined with poor supervision or performance management meant abusers were not identified and often able to act with impunity. Staff and carers who failed to report abuse and neglect, and people who failed to investigate complaints properly and report were also regularly not held to account.

408. In Part 7 and Beautiful Children: Inquiry into the Lake Alice Child and Adolescent Unit report, the Inquiry found that professional bodies failed to take timely and appropriate disciplinary action when complaints of abuse about staff were made. There was a lack of appropriate safeguarding standards to ensure prompt disciplinary action occurred. This meant that abusers were able to face minimal repercussions, with some able to continue working despite their abuse of children, young people or adults in care being known.

409. The Inquiry found that the Aotearoa New Zealand branch of the Australian and New Zealand College of Psychiatrists learned of Dr Selwyn Leeks’ conduct in the late 1970s but did not confront Dr Leeks or forcefully advocate for change.[194] Dr Leeks’ membership with the College remained in place until his death in 2022.[195]

410. Although schools must report teachers to the Teaching Council if they are subject to a complaint of abuse and neglect,[196] the Teaching Council told the Inquiry that teachers can currently seek voluntary deregistration and thus avoid an investigation into the complaint:

“Currently, a teacher is prohibited from voluntarily deregistering when a conduct or competence investigation is underway but a formal investigation may not be initiated until some weeks after the receipt of a report or complaint.”[197]

411. The Teaching Council of New Zealand told the Inquiry that when it censures a teacher and cancels their registration for sexually grooming or abusing a person in care, this information would not be shared with NZ Police as a matter of course. The information would therefore not be evident in any future vetting unless the survivor reported the abuse to NZ Police.[198]

412. Care providers and professional registration bodies must consistently and transparently hold people to account for credible allegations of abuse and neglect in care. Having clear and transparent disciplinary policies and procedures in place, and prompt disciplinary action when warranted, will strengthen safeguarding culture amongst care providers and staff and care workers. Effective professional discipline processes will also support public trust in care systems, which was fairly and understandably eroded due to a lack of accountability for abuse during the Inquiry period.

413. All State and faith-based care providers and professional registration bodies must report substantiated complaints to the Care Safe Agency and NZ Police. Care providers must also report substantiated complaints to the relevant professional registration body. The Inquiry would expect substantiated complaints of abuse or neglect to result in permanent deregistration.

414. The Inquiry is aware that there may be privacy implications and legislative or regulatory provisions relevant to care providers’ and professional registration bodies’ ability to report. The Inquiry envisages the government would review all relevant legislation to identify and address any such barriers.

415. The Inquiry intends that the Care Safety Act (Recommendation 45) will include appropriate penalties and sanctions for a failure to report substantiated complaints. The Inquiry also expects that the Care Safe Agency (Recommendation 41) will develop guidelines in relation to complaints, accountability and disciplinary action, that will include timeframes for investigations and action from relevant parties.

Tūtohi 66 | Recommendation 66

Where a complaint has been substantiated, State and faith-based entities providing care directly or indirectly and relevant professional bodies should take steps to ensure the person or people responsible are held accountable, including:

a) professional disciplinary action
b) reporting to the relevant professional registration body or bodies
c) reporting to the Care Safe Agency
d) reporting to NZ Police
e) reporting in accordance with any other applicable information sharing or mandatory reporting obligations.

Me whakaemi ngā kōamuamu, ngā whakakitenga me ngā pānga mahi tūkino
Centralised record of complaints, disclosure and incidents of abuse and neglect in care

416. The Inquiry has seen no evidence of a centralised database of complaints, disclosures and incidents of abuse and neglect in care, substantiated or unsubstantiated, across State and faith-based care settings. It is important that a single entity has the whole picture of complaints against individuals across the care system so that perpetrators cannot slip through the cracks. It will also facilitate building an evidence base and data analysis to create new insights into abuser behaviours, which can in turn inform new prevention and response strategies and practices.

417. The Inquiry intends that all complaints, disclosures and incidents of abuse and neglect in care will be reported to the Care Safe Agency by care providers, professional registration bodies and independent monitors. Reporting needs to have enough specificity about the person or persons subject to the complaint, the nature and extent of the complaint, and the outcome of the investigation, to enable the Care Safe Agency to keep a centralised record.

418. The Inquiry intends that all complaints, even where they are not substantiated following investigation, will be reported to the Care Safe Agency. The Care Safe Agency may choose to conduct its own investigation, as it may have received complaints about the same person from other entities. Careful judgment will be required to mitigate the risks that a person could be unjustly targeted by malicious or spurious complaints. The Inquiry does not intend for the Care Safe Agency to use unsubstantiated complaints as a reason to automatically deregister staff and care workers. If a reinvestigation results in the complaint being substantiated, then the Care Safe Agency must report this to NZ Police.

419. The Inquiry expects the Care Safe Agency to maintain a consistent focus on individuals identified as being at risk in the care system, ensuring people about whom a complaint or concern has been raised remain visible as their case is investigated and do not fall through the gaps. It is critical that the approach to complaints goes beyond a transactional process to include a holistic view of the person at the centre of the complaint. This will include ensuring that the views of the person identified as being at risk have been sought so that the Care Safe Agency understands that person’s reality and uses it to inform its investigations.

420. The centralised record of complaints must not be made publicly accessible, as it will include complaints against people that have not been substantiated following investigation. Its data will need to be internally protected to avoid inappropriate access from within the Care Safe Agency.

421. The Inquiry recognises the privacy and human rights implications of reporting unsubstantiated complaints between entities and keeping a centralised record of these. There may be existing legislative or regulatory barriers relevant to care providers’ and professional registration bodies’ use and transfer of this information. The Inquiry envisages the government would review all relevant legislation to identify and address any such barriers.

Tūtohi 67 | Recommendation 67

All State and faith-based entities providing care directly or indirectly and relevant professional registration bodies should report all complaints, disclosures or incidents to the Care Safe Agency, whether substantiated or not substantiated following investigation.

Tūtohi 68 | Recommendation 68

The government should enable, in legislation, the Care Safe Agency to collate and keep a centralised database of complaints, disclosures or incidents of abuse and neglect of children, young people and adults in care, for the purposes of:

a) reinvestigation, if considered necessary or appropriate
b) having a whole-of-system view to ensure that:

i) proven perpetrators cannot move between geographic locations, professions or care settings without detection
ii) people subject to multiple unsubstantiated complaints from different geographic locations, professions or care settings can be identified and steps taken if considered proportionate and appropriate

c) creating an evidence base and undertaking data analysis to create new insights into perpetrator behaviours, which can in turn inform new prevention and response strategies and practices.

He taki rīpoata motuhake
Mandatory reporting

422. During the Inquiry period, the State failed to ensure that effective and mandatory reporting practices were in place. Without mandatory reporting requirements, abusers were able to avoid accountability and go on to abuse more children, young people and adults in different care settings. Additionally, the lack of clear reporting requirements meant bystanders to abuse did not have clear guidance about when to report things of concern they had witnessed. The Inquiry found that bystanders frequently failed to intervene and report the abuse and neglect to relevant authorities.

423. Aotearoa New Zealand currently has a mix of criminal and setting-specific mandatory reporting laws for children and adults in care and broad-based voluntary reporting laws regarding children under the age of 18. Anyone can report suspected abuse or neglect of children. Abuse or neglect does not need to have happened; it can be enough that someone is concerned it is going to happen.

424. Staff and carers can voluntarily report abuse or neglect, or suspected abuse or neglect of children, to Oranga Tamariki or the police.[199] Many (but not all) staff and carers work in a care setting that must have a child protection policy in place that covers identifying and reporting abuse and neglect.[200] Reporting in these policies is linked to the voluntary reporting provision in section 15 of the Oranga Tamariki Act. Excluding the Crimes Act, its reporting laws do not apply to adults in care.

425. For many professions and settings (for example teachers), people must report concerns of abuse or neglect and will face serious sanctions if they do not. Sanctions include professional discipline, the loss of employment or a contract, and the loss of a license to operate.

426. Under the Crimes Act 1961, there are criminal sanctions for certain people who fail to take reasonable steps, which would include reporting abuse, to protect a child or adult, where they are at risk of sexual assault, grievous bodily harm or death.[201] The Inquiry notes, however, that the Crimes Act is not a mandatory reporting regime, as it does not provide protection to those making the report, and would likely apply only in fairly extreme cases.

427. There are mandatory reporting laws relating to teachers.[202] Schools must report teachers to the Teaching Council in cases of dismissals, issues of concern or complaints where the teacher has resigned or their contract has expired, and possible serious misconduct or competence issues. Court Registrars must report convictions of teachers to the Teaching Council. Teachers who have been convicted must also self-report to the Teaching Council. School boarding facilities must also report abuse or neglect.[203]

428. There has been ongoing debate about whether Aotearoa New Zealand should adopt widespread mandatory reporting (where all professionals who work with children are mandated to report suspected abuse to Oranga Tamariki). There continues to be no consensus on this issue. Widespread mandatory reporting was rejected in 1986 and in 1993. Dilworth survivors petitioned the Inquiry to make recommendations about a Dilworth Law, that would require a person or entity to report to police if a child or young person were at risk of serious harm.[204]

429. When considering mandatory reporting, the Inquiry contemplated recommending a comprehensive new widespread mandatory reporting regime covering all cohorts, professions and settings. While this would have benefits, including being a strong public repudiation of abuse and providing clarity about responsibilities to report, the Inquiry is concerned that it would have unintended systemic consequences. These could include an increase in surveillance, racism, discrimination and prejudice for Māori, Pacific Peoples, disabled parents, and communities experiencing persistent disadvantage. There is also a risk that the system could become overwhelmed and would be less able to focus on abuse prevention and community wellbeing initiatives.

430. The Inquiry recommends a balanced approach that seeks to ensure that mandatory reporting laws apply consistently across all the care settings the Inquiry investigated, to both State and faith-based entities providing care directly or indirectly, and consistently to people who come into contact with children, young people and adults in care, not just specific professions such as teachers.

431. The Inquiry also wants to recognise the steps taken following the Australian Royal Commission into Institutional Responses to Child Sexual Abuse regarding mandatory reporting and the Confessional Seal. Several Australian states enacted mandatory reporting laws in 2019. These laws now explicitly extend to religious and spiritual leaders, requiring them to report disclosures of abuse including those received during religious confession. Dr Christopher Longhurst, survivor advocate and national leader of SNAP (the Survivors Network of those Abused by Priests), has urged this.[205]

432. Because of the particular implications of mandatory reporting that may affect Māori, the Inquiry intends that the details of a coherent mandatory reporting regime, including who has a duty to report, what they must report on, and which entity or entities they have to report to, will be jointly developed by government and Māori in accordance with te Tiriti o Waitangi, tino rangatiratanga and self-determination. The Inquiry also expects the regime will be designed in line with implementation Recommendations 126–127.

Tūtohi 69 | Recommendation 69

The government should introduce legislation where necessary to create a coherent mandatory reporting regime which:

a) applies to all State or faith-based entities providing care directly or indirectly to children, young people and adults in care
b) applies to all staff and care workers who work for the entities, outlined in (a) above, including foster parents, volunteers, chief executives, trustees, board members, clergy and lay people and people in religious ministry who receive disclosures of abuse and neglect during religious confession
c) ensures obligations are clear, consistent, established in legislation and should include protections from liability for those making good faith notifications
d) ensures access to timely advice on reporting obligations.

Ngā wahi tiaki me ōna tikanga kia iti iho te mana, kia kore rawa atu rānei a tōna wa
Institutional environments and practices to be minimised and ultimately eliminated

433. During the Inquiry period, the environments and practices of many State and faith-based institutions contributed to the abuse and neglect of children, young people and adults in their care.

434. Many institutions across all settings the Inquiry investigated applied a heavily regimented one-size-fits-all model of care, with the same form of care applied to everyone regardless of their age, gender, abilities, culture, needs and reasons for being in care. Features of one-size-fits-all care, which are consistent with the defining elements of institutions identified by the United Nations Committee on the Rights of Persons with Disabilities,[206] included:

a. rigid routines that people in care had little influence or control over
b. identical activities shared by people in care, or groups of people in care
c. people in care having limited or no influence over who provided their care
d. a lack of control over day-to-day decisions, like activities or mealtimes
e. a lack of choice about who they lived with
f. isolation or segregation from the community
g. a disproportionate or high number of disabled people living in the same environment.

435. Other institutional practices that contributed to abuse and neglect in care included an emphasis on conformity, rules and order, which were often prioritised over the needs of people in care and enforced with harsh and abusive discipline. The use of pain compliance techniques, restrictive practices and solitary confinement constituted abuse.

436. Overcrowding and unsuitable facilities compromised basic standards of care and contributed to abuse and neglect. Overcrowding was common in psychiatric institutions, social welfare residences and in family homes, which led to reduced or absent oversight and reduced individualised care. Many institutions had substandard physical environments, such as old buildings that were poorly designed, or reflected military or prison-like environments.

Te turaki nohonga pūnaha taurima
Deinstitutionalisation of residential care settings

437. In the 1970s and 1980s, the State began responding to calls for deinstitutionalisation of care settings, particularly large psychopaedic and psychiatric institutions.

438. The Committee on the Rights of Persons with Disabilities recommended in 2022 that Aotearoa New Zealand should:

Develop a comprehensive deinstitutionalisation strategy, with specific timeframes and adequate budgets, to close all residential institutions, including group homes and residential specialist schools to provide community supports for persons with disabilities to live independently in the community.[207]

Kāinga kaitiaki, tū ārai mai
Care and protection residences

439. In 2022/23, Oranga Tamariki reported that there were 34 children and young people admitted to care and protection residences, and that there were four care and protection residences in operation.[208]

440. The Oranga Tamariki Future Directions Plan from September 2021 includes the intention to “close its current care and protection residences and replace them with a model that enables tailored care for tamariki with high and complex needs”.[209] In August 2022, Oranga Tamariki Chief Executive, Chappie Te Kani, told the Inquiry at the Inquiry’s State Institutional Response Hearing that Oranga Tamariki “has a clear view that the care and protection residences need to be closed down”.[210] However, at that time Oranga Tamariki did not have a planned timeframe for the closure of care and protection residences.[211]

Tūtohi 70 | Recommendation 70

The government should prioritise and accelerate current work to close care and protection residences, which perpetuate the institutional environments and practices that led to historical abuse and neglect in care.

Ētahi atu kāinga noho
Other residential facilities

441. There are residential facilities in youth justice, education, Deaf, disability and mental health settings. It is critical that the children, young people and adults in care in these facilities do not experience the kinds of institutional environments and practices that led to historic abuse and neglect in care. Any changes in this space will take time and should facilitate grandparenting of current arrangements alongside work to reduce and eliminate institutional environments and practices.

Ngā kāinga taiohi ā-ture
Youth justice residences

442. In 2022/23, 471 children and young people were admitted to youth justice residences. There were 24 operational youth justice facilities – five secure residences, 14 remand homes and five community bail homes.[212]

443. As set out in Chapter 3, the Inquiry envisages that very few children and young people would be placed in youth justice residences, because they would have had access to the supports and services they needed to flourish and would demonstrate fewer behaviours resulting from trauma or unaddressed needs. The Inquiry recognises that, in the immediate and medium term, there will still be situations where it is both necessary and appropriate for some children and young people to be placed into youth justice facilities to ensure their own, and the public’s, safety.

444. Oranga Tamariki Deputy Chief Executive Nicolette Dickson told the Inquiry that “there are some slightly different imperatives in a youth justice setting in terms of public interest and safety” than there are in care and protection residences. She also said that Oranga Tamariki is working to ensure that youth justice residences do not have “the harmful impact of a large, institutional environment”.[213]

Ngā kāinga tōpū hunga whaikaha
Group homes for disabled people

445. In 2019/20, although half of people receiving disability support services lived in their own homes, 16 per cent were living in a group home (called a community residential home).[214]

446. A 2013 report to the Minister of Health found, in relation to how the Ministry of Health handled complaints of abuse against three service providers, that:

“In all three cases there is evidence that attitudes existed that were reminiscent of an institutional approach to the care of people with disabilities. This culture, which sees people as a group, rather than as individuals with individual needs and preferences, is a clear warning signal of a lower quality of care.”[215]

447. A 2013 report on the experiences of disabled people recounted the experience of a new manager who had recently taken over a running a residential service:

“When I came here, emotional, and psychological abuse was prevalent … The abuse was pervasive. Every single client got it. … The place was institutionalised. The carers were not carers they were jailers. Clients just sat in corners and no rehab happened.”[216]

Ngā kura ā-noho motuhake
Residential specialist schools

448. There are currently three Residential Specialist Schools in Aotearoa New Zealand for students who have social, behaviour and/or learning needs that are highly complex and challenging – Westbridge Residential School in Auckland, Salisbury School in Nelson, and Halswell Residential School in Christchurch. The total number of students enrolled in the three schools was 71 in 2014 and fell to a low point of 17 students in 2021. Enrolments have recently increased across all three schools, totalling 40 students in 2023.[217]

449. In August 2022, at the Inquiry’s State Institutional Response Hearing, Secretary for Education Iona Holsted acknowledged that “there are instances where some disabled and Deaf tamariki are still not able to access the full curriculum and wider education experience”.[218]

450. In September 2022, the United Nations Committee on the Rights of Persons with Disability recommended that Aotearoa New Zealand should close and stop investing in Residential Specialist Schools and significantly increase supports and services for children with disabilities and their families to prevent out of home placements, including in Residential Specialist Schools.[219] It also recommended the devolution of “segregated education settings” into a mainstream inclusive education system.[220]

451. In March 2023, the Ministry of Education included, in its list of actions that would require the input of the Minister of Education by the end of June 2023, “decide on how to respond to the recommendations from the UN Committee on the Rights of Persons with Disabilities regarding residential specialist schools.”[221] A Cabinet paper published in August 2023 seeking agreement to the government’s response to the Committee’s observations included “the role of specialist schools” and “the role of residential special schools” in its list of “significant and contested areas of government policy”.[222] The Cabinet paper noted that:

“The UN Committee has provided recent guidelines on deinstitutionalisation. They clearly indicate that schooling settings like residential specialist schools are seen as institutional given that they are only available to children based on impairing factors like behaviour. The Guidelines also indicate that institutional settings cannot be seen as an authentic choice for students and their families. The Ministry of Education has noted recommendations related to Residential Specialist Schools subject to further consideration of New Zealand based research and evidence and decisions by the Minister of Education. Unlike other noting recommendations, there is a possibility that these could be changed after the Minister’s consideration.”[223]

452. The Inquiry has not seen evidence that the government has made any decisions relating to Residential Special Schools since June 2023.

453. In the Australian Disability Commission report, Commissioners had differing views about the ongoing role of specialist schools. Three Commissioners, including the two disabled Commissioners, considered that all special schools should be closed on the grounds that they constituted segregation of disabled people, which is a significant human rights issue. The other three Commissioners did not agree, stating that they did not share the assumption that specialist schools for students with complex support needs “inevitably must isolate those students from their peers in other educational institutions”.[224]

Ngā kura ā-rangi motuhake
Day specialist schools

454. Day specialist schools offer specialist teaching to students who have a high level of need from Years 1 to 13. In addition to having a base school, many day schools have satellite classes attached to mainstream schools. There are around 28 day specialist schools in Aotearoa New Zealand with a combined total roll of around 4,000 children and young people.[225]

455. The Inquiry heard from families of survivors about institutional practices and environments being experienced at day specialist schools:

“Our son, Rovin Turnbull, experienced physical and psychological abuse, including restraint and seclusion, while at school.”[226]

“Keegan was excluded from school camp due to his high needs.”[227]

456. The Inquiry heard voices in support of inclusive education as evidence-based and meeting human rights obligations, with some viewing special schools as incompatible with the right to inclusive education.[228] Survivor and advocate Matthew Whiting told the Inquiry that special schools should be closed, but that to do so “we need to support people really well … at home, at school, anywhere”.[229]

457. There is a diversity of views in Aotearoa New Zealand about segregated education settings. In its engagements with the Deaf community, a strong theme was that education in mainstream settings often does not work for them and that there is a need for Deaf students and teachers to have spaces together, as the education system is hearing-centric.[230]

458. Disability organisations have called for inclusive education to become a reality so that disabled students and whānau can make genuine, informed choices about their education. A 2015 submission from a group of Aotearoa New Zealand disability organisations summed it up as follows:

“… people in New Zealand often hold different views on how to ensure the best education for disabled children. We do not always agree with each other. Some people view a special school or unit is the best choice for their child…For choice to be real, however, there must be universal access to a fully inclusive education in local early childhood, compulsory primary and secondary and tertiary settings and equity of funding.”[231]

Tūtohi 71 | Recommendation 71

The government should, as a priority, support and invest in the development of disability and mental health, educational and youth justice models of care that do not perpetuate the institutional environments and practices including segregation that led to historic abuse and neglect in care.

Me muru rawa ngā tikanga whakamamae me te here tangata
Pain compliance techniques and other restrictive practices to be banned

459. During the Inquiry period, many survivors shared that staff would use restrictive and violent practices to manage the behaviour of children, young people and adults in care.

460. The Inquiry notes that not all forms of restraint constitute restrictive practice. If restraint is necessary and appropriate to ensure safety, such as the use of safety belts in wheelchairs, then it does not amount to a restrictive practice. The unnecessary and inappropriate use of restraint would, however, be considered a restrictive practice. Examples of inappropriate use of restraint include using physical or chemical restraint (using medication such as sedatives) to control a person’s behaviour. The Inquiry also heard about care workers removing wheelchair batteries to prevent their ability to move. Restraint also frequently had elements of punishment.

461. Ms PX, who worked at Kingslea Residential Centre (later Te Oranga) from early 2000 to 2005 as a youth worker, told the Inquiry that she witnessed staff using “excessive force with an inappropriate restraint” multiple times.[232]

462. In 2022, the Office of the Children’s Commissioner reported to the United Nations Committee on the Rights of the Child that:

“Between July 2017 and March 2021 [school students] between the ages 4 and 18 were restrained 7,662 times.

Restraint [in youth justice residences] is often used excessively, inappropriately, and has resulted in harm and injury to mokopuna, including for those who witness it.

Restraint chairs are still being used by the New Zealand Police for mokopuna as young as 13, despite being considered ‘inherently degrading’”.[233]

463. A 2023 Oranga Tamariki report acknowledged that “it is likely that physical restraint is disproportionally used on young people who identify as Māori, simply by virtue of the fact that Māori youth are significantly overrepresented in Oranga Tamariki youth justice residences”.[234]

464. A 2020 report commissioned by Te Kāhui Tika Tangata Human Rights Commission to review the use of restrictive practices in (among other settings) care and protection, youth justice, health and disability and police settings, found that:

“Without a significant shift in the very way that detaining agencies think about the extreme tools of seclusion and restraint, a meaningful change will be impossible to achieve.”[235]

465. There is a need to set clear standards and expectations that prohibit the use of pain compliance techniques and the use of restrictive practices in all State and faith-based care settings and to promote alternative practices.

Tūtohi 72 | Recommendation 72

The government should take steps to ban pain compliance techniques in any care setting for children, young people and adults in care.

Tūtohi 73 | Recommendation 73

The government should ensure there are adequate frameworks in place to govern the use of restrictive practices for children, young people and adults in care to minimise the use of those practices (ensuring they are used only as a last resort) and provide for adequate safeguards and checks.

Te mauhere tū tāhanga, me whakaiti, ā tōnā wā me muru rawa atu
Solitary confinement to be minimised and ultimately eliminated

466. The damaging effects of solitary confinement are considerable. Research demonstrates that solitary confinement causes long lasting physiological and psychological impacts on people’s intellect and behaviours, social and emotional regulation, mental and physical health, memory, and on their brain structure and function.[236]

467. During the Inquiry period, some care settings had standards that limited the use of solitary confinement (often called “seclusion”). For example:

a. in social welfare settings, standards from 1957 stated that solitary confinement was generally only to be used as an emergency procedure, and 1986 regulations stated it was not to be used for punishment[237]
b. in education settings, 1986 guidelines on the use of timeout stated that it should not be used for longer than a matter of minutes[238]
c. in mental health settings, legislation allowed its use only if necessary, where, and for as long as, it was necessary for the care or treatment of the patient, or the protection of other patients.[239]

468. At the Inquiry’s State Institutional Response Hearing in August 2022, Chappie Te Kani, Chief Executive of Oranga Tamariki, agreed that the “history of treatment of children in solitary confinement” in children’s homes was inhumane.[240] At the same hearing, Dr Diana Sarfati, Director-General of Health, acknowledged that there was inappropriate use of seclusion and restraint in psychopaedic and psychiatric settings during the Inquiry period.[241] The Inquiry found that there was overuse of seclusion and solitary confinement, at times unlawfully, during the Inquiry period.

469. In its 2022 concluding observations on the combined second and third periodic reports of Aotearoa New Zealand, the United Nations Committee on the Rights of Persons stated it was:

“…seriously concerned about the continued, and in some cases prolonged use of solitary confinement, seclusion, physical and chemical restraints and other restrictive practices on persons with disabilities, in particular persons with psychosocial and/or intellectual disabilities, in places of detention.”[242]

470. In 2019, the Health Quality and Safety Commission launched its Zero Seclusion: Safety and dignity for all project,[243] which aimed to “contribute to the goal of eliminating solitary confinement in mental health. In April 2023, the Ministry of Health’s updated guidelines on preventing and safely reducing and eliminating seclusion and restraint in mental health settings observed that “seclusion and restraint have no therapeutic benefit, and in fact can be harmful and traumatic to tāngata whaiora [and] their whānau”.[244]

471. The Director of Mental Health and Addiction Services noted that, between 1 July 2021 and 30 June 2022, Māori were 5.5 times more likely than non-Māori to have been placed in solitary confinement while under a compulsory treatment order, which was “an increase in the rate for Māori and a decrease for non-Māori, widening the inequity gap between the populations”.[245]

472. It is critical that action be prioritised to eliminate the use of solitary confinement and ensure that the individual needs of people in care are met. Focus should be placed on reducing overrepresentation of Māori people experiencing solitary confinement.

Tūtohi 74 | Recommendation 74

The government should prioritise and accelerate work to minimise and eliminate solitary confinement in all care settings as soon as practicable, with an emphasis on person-centred and culturally appropriate approaches to reduce the use of solitary confinement safely.

Te waihanga papa ā-noho, e iti iho ai, ngā mahi tūkino i ngā pūnaha taurima
Physical environments designed to reduce risks of abuse and neglect in care

473. During the Inquiry period, the physical design of some settings failed to provide residents with their rights to privacy, dignity and respect. International inquiries have found that substandard physical living conditions that fail to afford human dignity contribute to abuse.[246]

474. Some settings, particularly residential institutions, were designed to contain and restrict movement, rather than create safe and homely environments. The Inquiry saw this through the regular use of solitary units and seclusion rooms where children, young people and adults were placed into individual cells with limited visibility and oversight. Solitary cells enabled perpetrators unsupervised access to survivors and were one of the most common locations of abuse that survivors shared with the Inquiry. Some facilities, such as Kimberley Centre, had open toilets without doors, which prevented residents’ basic rights to privacy and dignity.

475. Institutions such as Hokio Beach School and Kohitere Boys’ Training Centre, and Te Whakapakari Youth Programme were some of the most extreme examples the Inquiry saw of substandard living conditions. They demonstrated the harmful impacts that punitive or corrective bootcamp-style approaches to care have on children and young people. Experts agree that this approach is more likely to lead young people into the criminal justice system.[247]

476. A 2020 Office of the Ombudsman inspection report on the mental health inpatient unit at Waikato Hospital found that:

“There were still no coverings to provide privacy for service users in seclusion rooms. While external bedroom windows had mirrored covers to prevent observation from the courtyard, internal windows remained uncovered. Service users in seclusion rooms could be observed when sleeping, or in various stages of undress, through the internal windows.”[248]

477. A 2021 Office of the Ombudsman inspection report on the Te Whare Ahuru mental health inpatient unit at Hutt Hospital found that:

“The Unit, which opened in 1995, was no longer fit for purpose. The standard of cleanliness was a significant issue and maintenance was not being attended to within acceptable timeframes. Carpet in communal areas was observed by Inspectors to be badly stained and in a state of disrepair. One client told Inspectors they had to open a window in the acute ward TV lounge due to the overwhelming smell of the soiled carpet.”[249]

478. A 2023 inspection report by the Children’s Commissioner on Te Puna Wai ō Tuhinapo youth justice residence in Christchurch observed that:

“The showers were in a disgusting state and in need of repair. A staff member said, “I wouldn’t want to shower in there”. There was scrunched toilet paper that had been thrown on the ceilings, and marks on the walls that resembled faeces. The bedrooms were full of tagging, the floors were filthy, and the communal rooms are generally in poor condition. … The units are in poor condition and are unfit for mokopuna. Graffiti is present on the walls, windows, and the ceilings. Units are dirty, wet tissue paper has been scrunched up and thrown on the ceilings and many rooms in the residence smell damp. Bedrooms are dark with poor ventilation, and room temperatures range from extremely hot to freezing cold.”[250]

479. At the Inquiry’s State Institutional Response Hearing in 2022, the Inquiry was told by Chief Social Worker Peter Whitcombe that “we have CCTV camera footage of the areas throughout secure. The parts of secure that aren’t covered are the young person’s bedrooms and bathroom and toilet, but that is the only areas that are not covered by CCTV footage”.[251] There needs to be an appropriate balance between upholding the rights of people in care to privacy and dignity and mitigating the risks associated with isolated spaces that could be used by abusers to escape scrutiny. International inquiries have found that isolated physical spaces can contribute to abuse and neglect.[252]

480. The physical design of care settings needs to meet human rights obligations and standards and be designed to prioritise safeguarding. This may mean significant renovation of some settings to meet these standards and obligations. Care settings should not be physically or geographically isolated and must support connections to the wider community, be developmentally appropriate and accessible for visitation. The Inquiry also considers there is merit in exploring whether technology such as CCTV and body cameras can be used to enhance residents’ safety without unduly infringing personal privacy and remaining aligned with the principles in the Privacy Act 2020.

Tūtohi 75 | Recommendation 75

All State and faith-based entities providing direct or indirect care to children, young people and adults should review physical building and design features to identify and address elements that may place children, young people and adults in care at risk of abuse and neglect. This should include:

a) consideration of how best to use technology such as CCTV cameras and body cameras without unduly infringing personal privacy, including taking into account any applicable guidance documents and the legal requirements for the collection of personal information under the Privacy Act 2020
b) reviewing any policies or processes that place children, young people or adults in care with others who may put them at risk (for example, children and young people in care and protection being placed together with children, young people or adults in the justice system)
c) if care settings include physically isolated spaces, for example private offices or a confessional box, ensuring there are tailored measures in place to address the risks arising, including the risk of undetected abuse and neglect
d) if care is to be delivered in a geographically isolated or remote area, ensuring there are tailored measures in place to address the risks arising from the geographical setting, including the risk of undetected abuse and neglect.

Me whakamana, me tautoko te hunga kei ngā pūnaha taurima
People in care are empowered and supported

Te whakatū kaupapa motuhake hei reo mo te hunga kei ngā pūnaha taurima
Setting up a system of independent advocates for all people in care

481. Many of the Inquiry’s findings have emphasised the disempowered position of people in care, particularly those whose human rights to self-determination and decision-making, including rights under te Tiriti o Waitangi, were overridden or denied. Children, especially tamariki Māori, young people including rangatahi Māori, and disabled children and young people including tamariki and rangatahi hauā were undervalued, had no voice and were often not understood or believed.

482. In Part 7, the Inquiry observed that many survivors lacked access to an independent advocate, to tell them about their rights while in care, and to support them or represent them to make complaints and prevent and respond to abuse and neglect.

483. Independent advocacy should be freely available to all children, young people and adults in care, to support them to understand and exercise their rights.

484. The Health and Disability Commissioner has acknowledged that “advocacy numbers have not kept pace with population growth and health service activity, and do not necessarily reflect the diversity of their communities”.[253] Dr Mhairi Duff, a Deputy Clinical Director at the Mason Clinic told the Inquiry:

“If I had a pot of gold to invest in, I would have far more consumer advisors and advocacy. The number of consumer advisors is grossly inadequate. You could very easily have someone on every unit.”[254]

485. In their monitoring report into Te Whare Tuhua and Te Whare Matariki remand homes in 2022, Mana Mokopuna found:

“Mokopuna in Te Whare Tuhua me Matariki do not have access to independent advocates like VOYCE Whakarongomai. Neither staff or mokopuna we spoke to knew how to access this service.”[255]

486. The Independent Children’s Monitor’s 2024 annual report noted that:

“…we continue to hear that tamariki and rangatahi in care do not routinely understand their rights. This raises the question of whether this may be impacting on their ability to voice complaints.”[256]

487. The Inquiry recommends that each child, young person and adult in care and protection, youth justice, disability and mental health settings has access to an individual advocate, and that they can exercise choice in deciding which advocate is right for them. In education settings, the Inquiry recommends that each State, integrated and private school has at least one advocate per school to support the children and young people in school to understand and exercise their rights. This would complement existing support programmes such as Social Workers in Schools.[257]

488. Independent advocates will need to be subject to the same regulatory standards and safeguards as others in the care workforce. They will need to be vetted, registered, and appropriately trained. Some may be unpaid volunteers. For people who require more than short-term care, the Inquiry would expect advocates to aim for long term relationships with the person in care. Independent advocates with recent lived experience of being in care would be a significant asset in this workforce and will add value to care environments. The Inquiry recommends the Care Safe Agency should develop a career pathway for people with lived experience of care to become independent advocates. This pathway will need to consider how to remove barriers that restrict care experienced people, people with neurodiversity and low literacy skills (for example) from employment.

Tūtohi 76 | Recommendation 76

The government should:

a) provide sufficient investment to enable children, young people and adults in care to have access to an independent advocate of their choosing to support them to understand and exercise their rights, specifically:

i. each child, young person and adult in care and protection, youth justice, disability and mental health settings should have access to an individual independent advocate
ii. children and young people in State, State-integrated and private schools should have access to at least one independent advocate per school

b) provide that independent advocates:

i. have appropriate communication skills (including for Deaf and disabled people in care)
ii. be independent from the care provider, and staff and care workers
iii. be independent from the direct and immediate whānau of the person in care
iv. proactively and regularly engage with the person in care, be available to respond in times of need, support the person in care when they need to raise issues with their carer, advocate for the right conditions, and/or generally provide peer support
v. have no power over the individual

c) provide that advocates are subject to the same regulatory standards and safeguards, including vetting, registration and training as other staff and care workers.

Tūtohi 77 | Recommendation 77

The Care Safe Agency should develop a career pathway for people with previous lived experience of care towards becoming an independent advocate.

Me whānui ngā whiringa tokonga hiahia e rite ana mo ngā manako o ia tangata
Needs assessment to be comprehensive and respond to needs of the person

489. Many care settings did not identify the individual needs of those in care. Instead, many settings prioritised a “one-size fits all” approach focused on discipline, order and conformity, and paid insufficient attention to avoiding and detecting abuse and neglect.

490. All individuals have different perspectives and challenges and catering to those will have a bigger impact on lives than a ‘one-size fits all’ approach. For tamariki, rangatahi and pakeke Māori in care, this would include understanding and providing for cultural needs in a way that enhances their mana and mauri. All entities providing care directly or indirectly should understand these perspectives and challenges to ensure that the care and support provided meets their individual needs.

Tūtohi 78 | Recommendation 78

All State and faith-based entities providing care directly or indirectly should seek the best possible understanding of the background, culture, needs and vulnerabilities of every child, young person and adult in their care, and should include the protection and enhancement of the mana and mauri of Māori in care.

Kia tōtika ai ngā tokonga mahi atawhai kōhuki, me pātata mai te whānau o taua tangata ake e mau tonu ai ngā here atawhai
All involuntary care placements to be appropriate and located near the whānau of the individual in care to maintain attachment

491. Across many care settings during the Inquiry period, people in care were often removed involuntarily and placed far away from their whānau, communities, culture, support networks and mainstream society. This geographical isolation not only physically separated survivors from those closest to them, but disrupted their emotional connections, support and attachments, causing psychological harm. For Māori and Pacific survivors, separation from whānau played a major role in the cultural disconnection they then experienced.

492. The Inquiry found that moving children, young people and adults in care away from their whānau and communities also increased their vulnerability to abuse and neglect in care. Separation meant they had limited access to people they could trust and disclose abuse and neglect to and therefore undermined the development of protective factors.

493. A 2022 Mana Mokopuna monitoring report into the Epuni care and protection residence found:

“At the time of the visit, there were no mokopuna who were local to the Wellington region. Many mokopuna were from Auckland and said they felt isolated from whānau, friends and a familiar environment.”[258]

494. It is critical that clear action is taken by government and State and faith-based care providers to identify and address barriers to maintaining connections and attachments to whānau for people in care. This includes identifying and promoting good practice in supporting whānau connections.

Tūtohi 79 | Recommendation 79

The government and all relevant decision-makers should review existing policy, standards and practice to ensure that all involuntary care placements are suitable and support connection to whānau and community. This includes placements being located as close as reasonably practicable to the family or whānau of the children, young person or adult in care.

Tūtohi 80 | Recommendation 80

All State and faith-based entities providing care directly or indirectly should review existing policies and practice to ensure they promote and support the maintenance of connections and attachment to family and whānau wherever possible and appropriate.

Kia tōtika ngā kohinga me ngā tukunga raraunga, me ngā tuhinga kōrero
Best practice data collection, record keeping and information sharing

Me whakatinana ētahi mātāpono tiaki takinga kōrero
Implement records and record-keeping principles

495. The Inquiry found that many State and faith-based institutions had poor record keeping and data practices. This led to a lack of accountability and external scrutiny, and missed opportunities for detecting abuse and neglect. It also contributed to abuse and neglect continuing. To build social inclusion in a rapidly diversifying society, public sector agencies need to be able to collect the right data on Aotearoa New Zealand’s population to enable analysis of the implications of changing ethnic, disabled and religious demographics and the development of appropriate policy responses.

496. Having accurate and up to date records is critical to understanding the individual needs of those in care, meeting those needs and providing continuity of care while a child, young person or adult is in care.

497. Accurate data is also required to assess impacts and outcomes of policies and practices on meeting needs of the groups most represented in care. In Part 7 the Inquiry found that record-keeping issues, such as ethnicity not being recorded or the loss of records, meant the numbers of Māori and Pacific Peoples, Deaf, disabled people, people who experience mental distress, and Takatāpui, Rainbow and MVPFAFF+ people who were in care will never be known.

498. Today there are gaps in data collection. For example, the Ministry of Education has said that neurodiversity and disability are not characteristics collected by the Ministry in student data in ways that allow system analysis. Additionally, many neurodivergent students are undiagnosed.[259] The Independent Children’s Monitor noted in its 2022/23 annual report that while “monitoring over the last three years has shown a continuous improvement by Oranga Tamariki in completing assessments and individual plans that include the health needs of tamariki and rangatahi in care…the ongoing absence of reliable data is a major barrier to understanding how well tamariki and rangatahi in care are having their health needs met”.[260]

499. More comprehensive, granular data collection about the demographics and needs of people in care and independent evaluation of that data will mean better informed decisions and ensure that the benefits of government policies and programmes can be shared equitably. This analysis must inform policy decisions across the care system, and more broadly across social policy settings. They are complex and critical to addressing the social inequities that persist in Aotearoa New Zealand today.

500. This data must also be maintained appropriately and in an indexed, logical and secure manner to ensure that an individual’s rights to access, amend or annotate records about themselves should be recognised to the fullest extent.

Tūtohi 81 | Recommendation 81

All State and faith-based entities directly or indirectly providing care to children, young people, Deaf, disabled people and people who experience mental distress should adopt and comply with best practice guidelines for record keeping and data sovereignty, including the following principles:

a) Record-keeping Principle 1: To create and keep full and accurate records.

Creating and keeping full and accurate records relevant to safety and wellbeing is in the best interests of children, young people and adults in care and should be an integral part of institutional leadership, governance and culture. Institutions that care for or provide services to children, young people and adults in care must keep the best interests of the child uppermost in all aspects of their conduct, including recordkeeping. It is in the best interest of children, young people or adults in care that institutions foster a culture in which the creation and management of accurate records, including detailed information about ethnicity and impairments, are integral parts of the institution’s operations and governance.

b) Record-keeping Principle 2: Records to include all incidents and responses.

Full and accurate records should be created about all incidents, responses and decisions affecting the safety and wellbeing, including abuse and neglect in care, of children, young people or adults in care. Institutions should ensure that records are created to document any identified incidents of grooming, inappropriate behaviour (including breaches of institutional codes of conduct) or abuse and neglect in care, and all responses to such incidents. Records created by institutions should be clear, objective and thorough. They should be created at, or as close as possible to, the time the incidents occurred, and clearly show the author (whether individual or institutional) and the date created.

c) Record-keeping Principle 3: Records to be maintained in an indexed, logical and secure manner.

Records relevant to the safety and wellbeing of children, young people or adults in care, including abuse and neglect in care, should be maintained appropriately and in an indexed, logical and secure manner. Associated records should be co-located or cross-referenced to ensure that people using those records are aware of all relevant information.

d) Record-keeping Principle 4: Records only be disposed of in accordance with law or policy.

Records relevant to the safety and wellbeing, including abuse and neglect in care, of children, young people or adults in care should only be disposed of in accordance with law or policy. Records relevant to the safety and wellbeing, including abuse and neglect in care, of children, young people or adults in care must only be destroyed in accordance with records disposal schedules or published institutional policies. Records relevant to abuse and neglect in care should be subject to minimum retention periods that allow for delayed disclosure of abuse and neglect by victims and survivors and take account of limitation periods for civil actions for abuse and neglect in care.

e) Record-keeping Principle 5: Individuals’ rights to access, amend or annotate records about themselves to be recognised to the fullest extent.

Individuals’ existing rights to access, amend or annotate records about themselves should be recognised to the fullest extent including in a way that is compliant with the Convention on the Rights of Persons with Disabilities. Individuals whose childhoods are documented in records held by all entities providing care directly or indirectly should have a right to access records made about them. Full access should be given unless contrary to law. This includes the right to access records without redaction. Specific, not generic, explanations should be provided in any case where a record, or part of a record, is withheld or redacted. Consent of the person who is currently or was previously in care should be proactively sought if information needs to be shared with family members.

Tūtohi 82 | Recommendation 82

All State and faith-based entities providing care directly or indirectly to children, young people or adults should, together with the person in care, document an account of their life during their time in care.

Tūtohi 83 | Recommendation 83

All State and faith-based entities providing care directly or indirectly to children, young people or adults should be required to retain records relating to alleged abuse and neglect in care for at least 75 years in a separate central register, to allow for delayed disclosure and redress claims or civil litigation.

Me aromātai tonu ngā whakaritenga toha kōrero e hāngai tonu ai te kaupapa
Information sharing provisions to be reviewed to ensure fit for purpose

501. During the Inquiry period, the State failed to ensure that effective information sharing arrangements practices were in place. This prevented different government agencies from collaborating to prevent abuse and meant there were missed opportunities for detecting abusers.

502. There were attempts to encourage government agencies to collaborate, through information sharing arrangements or memoranda of understanding, however they were ineffective with little evidence that their collaborative efforts prevented abuse and neglect.

503. Since 1999, legal requirements to collect data and arrangements to share information between agencies have been introduced. In 2015, an Information Sharing Agreement was signed for Improving Public Services for Vulnerable Children between the Ministries for Social Development, Health, Justice, Education, and NZ Police. This included information about people who may pose a risk to children and information about that risk.

504. At the Inquiry’s State Institutional Response Hearing, Chief Executive of Oranga Tamariki, Chappie Te Kani, highlighted barriers to information sharing experienced by Oranga Tamariki as part of its safety checking process:

“We don’t have an agreed protocol which shares that information. So to answer your question, if there are a number of unsubstantiated allegations against teachers held in a centralised place by the Ministry [of Education] or the teacher’s discipline tribunal, we wouldn’t have access to that as an organisation by right.”[261]

505. There is a need to ensure information sharing arrangements are reviewed and strengthened to ensure agencies have access to the best information to prevent abuse in care.

Tūtohi 84 | Recommendation 84

The government should consider, in consultation with the Privacy Commissioner, whether existing information sharing provisions are sufficient to enable adequate sharing of information to prevent and respond to abuse and neglect in care, or whether additional tools are needed. This work should take into account the recommendations of the Australian Royal Commission into Institutional Responses to Child Sexual Abuse, “establishing a national information exchange scheme across sectors”. The purpose of the review should be to ensure all bodies (whether State or non-State) providing care to children, young people or adults can access the information they need to prevent and respond to abuse and neglect. The review should consider, among other things, whether non-State bodies should be empowered to share information more readily with both State and non-State bodies to prevent and respond to abuse and neglect.

He taurite me te whai rawa i ngā mahi aroturuki motuhake
Independent oversight and monitoring is coherent and well-resourced

506. During the Inquiry period, the State failed to ensure that there was robust, independent oversight and monitoring of all care settings that interacted effectively for people at risk. 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, policies, or providing safe and quality care.

507. Until the 1990s, limited monitoring enabled State and faith-based institutions providing care to operate in closed environments away from external scrutiny. There were minimal checks to ensure the rights and safety of children, young people and adults in care were being upheld. What oversight and monitoring did exist lacked the independence required to scrutinise institutions effectively and impartially, or to focus on people at risk. This led to missed opportunities to identify and prevent systemic abuse and neglect and rendered people at risk invisible within the system overviews that were available.

508. During the Inquiry period, the State implemented independent or semi-independent oversight and monitoring mechanisms in social welfare and education settings, including the creation of visiting committees for children’s residences and the creation of the Education Review Office to monitor State and State-integrated schools.

509. Several independent monitoring entities, including the Te Kāhui Tika Tangata Human Rights Commission, Children’s Commission and Health and Disability Commissioner were established towards the end of the Inquiry period, which added greater independence and rights protection for people in care. However inadequate resourcing meant that these functions had little capacity to undertake system level monitoring let alone focus on people at risk. There were also gaps in monitoring regimes, for example private schools. The Inquiry saw no evidence of any Māori-specific monitors during the Inquiry period.

510. Currently, the Ombudsman, as an Officer of Parliament, remains the only monitoring entity that is completely independent of the government. Other independent entities that currently have an oversight and/or monitoring role in relation to care settings include the Te Kāhui Tika Tangata Human Rights Commission, Health and Disability Commissioner and Mana Mokopuna – Children and Young People’s Commission.

511. In relation to the independence of monitoring and the Independent Children’s Monitor, the former Children’s Commissioner Judge Eivers told the Inquiry that:

“…the State cannot monitor itself. No matter how many non-interference agreements we are told are in place, or assurances that it is independent, the Independent Children’s Monitor that will undertake most of the monitoring of the care system is a departmental agency and can’t be independent of government.”[262]

512. Te Kāhui Tika Tangata Human Rights Commission shared similar views in their submission to the Oversight of Oranga Tamariki System and Children and Young People’s Commission Bill:

“Independence is crucial for the Independent Children’s Monitor to achieve its objectives of providing objective and impartial monitoring of the Oranga Tamariki system…A monitor that is not completely independent of government will struggle to gain the public trust and confidence…that is necessary to address (the failures of abuse in care).”[263]

513. In an article on the Oversight of Oranga Tamariki System Bill in 2022, Jonathan Boston and David King wrote that:

“…two types of monitoring and two types of advice are required. One type of monitoring and advice is fully independent. Such monitoring and advice is necessary to provide public confidence that there is a credible ‘watchdog’ for children and young people. The other is monitoring ‘responsive’ to government policy and advice that is ‘trusted’ and ‘responsive’.”[264]

514. Te Kāhui Tika Tangata Human Rights Commission also told the Inquiry that, in terms of resourcing of monitoring functions:

“…until 2019, the Commission had not received additional funding since 2007. In 2019, the Commission received a baseline funding increase for the first time in several years.”[265]

515. Mana Mokopuna told the Inquiry that over the years they have received additional places of detention to monitor “with minimal baseline adjustment [to funding] to supplement staffing levels”.[266] Limited funding has enabled them “to monitor, some, but not all, places of detention on an annual basis”.[267]

516. In 2022 the Chief Ombudsman told the Inquiry he has received increased funding to be able to carry out his new functions:

“I am funded at a level that enables me to undertake inspections of places of detention within my current jurisdiction under the Crimes of Torture Act 1989 at least once every four years – more regular inspections would require more resources.”[268]

517. In terms of capacity to undertake systemic monitoring, the Health and Disability Commissioner acknowledged it is under significant pressure from the increasing volume of complaints and its “ability to undertake systemic Commissioner-initiated inquiries in the absence of a complaint has become somewhat constrained.”[269]

518. Judge Eivers also highlighted concerns about system coherence:

“…instead of it all [oversight functions] being in one agency, we’ve now got three agencies [the Independent Children’s Monitor, Mana Mokopuna and the Ombudsman], where its whānau have to navigate their way through three agencies.”[270]

519. Dr Tristram Ingham told the Inquiry that, in relation to safeguarding arrangements for disability settings:

“None of the existing processes for service oversight, monitoring and safeguarding are sufficiently robust, all-encompassing or with sufficient teeth to provide timely and appropriate safeguarding for tāngata whaikaha Māori.”[271]

520. The Inquiry considered and rejected recommending that a new independent oversight and monitoring entity be created for the care system. The Inquiry thinks there is already a possibility of unnecessary duplication and overlap, especially in relation to independent monitoring of care and protection and youth justice settings.

521. The Inquiry recommends the government reviews existing entities’ roles and functions to:

a. identify and address any unnecessary duplication of effort as an immediate priority. The Inquiry envisages this will include consolidation of care and protection and youth justice independent monitoring into a single entity
b. determine the extent to which the existing entities are resourced and enabled to maintain a consistent focus on individuals at risk in the care system, ensuring people about whom a complaint or concern has been raised remain visible as their case is investigated and do not fall through the gaps.

522. The Inquiry intends that the independent monitoring and oversight entities, as they stand following this review, will have a critical role in providing an extra layer of oversight for the care system that operates at arm’s length from care providers and the Care Safe Agency. The monitoring and investigation roles of the Care Safe Agency do not constitute an overlap of responsibility with independent oversight entities. They are an additional layer of protection to ensure that there is a holistic view of people at risk in care, as well as the system level views they will provide.

523. The role of independent oversight and monitoring entities is separate and additional to the monitoring functions of the Care Safe Agency. The Care Safe Agency will proactively monitor and enforce compliance with statutory requirements, standards and rules under the new care safety regulatory system, including that care providers must be accredited, have complaints procedures in place, have safeguarding policies and procedures in place, vet employees, and ensure employees are registered and appropriately trained. The Care Safe Agency will also be responsible for investigating and responding to complaints, disclosures or incidents of abuse and neglect in care, as well as concerns or reports about breaches of rules, standards and guidelines under the care safety regulatory system.

524. The independent monitoring entities will also operate proactively to inspect care providers and visit facilities, as well as reactively investigating and responding to complaints about abuse and neglect in care or failures breaches of rules, standards and guidelines under the care safety regulatory system. The Inquiry also considers that the independent monitoring entities may choose to collaborate, as appropriate. Some independent entities are already working together to monitor children and young people in care and protection.

525. This means that people receiving care supports and services, whānau, staff and care workers, and anyone else who wishes to make a complaint, raise a concern or report abuse and/or neglect, will have four pathways to do so:

a. to the relevant State or faith-based care provider
b. to the relevant professional registration body
c. to the Care Safe Agency
d. to independent oversight and monitoring entities.

526. These bodies range from least independent (care providers) to most independent (independent monitoring entities). Complainants will be able to contact one or more entity about the same issue if they wish. Care providers and professional registration bodies will be required to report substantiated complaints to the Care Safe Agency (Recommendation 66). Complaints about the Care Safe Agency itself could be made to the Agency or to the independent monitoring entities.

527. The independent monitoring entities may require extra resourcing to investigate complaints or concerns and monitor additional statutory requirements, standards and rules under the new care safety regulatory system. They may also require extra investment to collaborate to enable a whole-of-system view when needed.

Tūtohi 85 | Recommendation 85

The government should:

a) review the roles, functions and powers of independent monitoring and oversight entities to identify and address any unnecessary duplication and encourage collaboration
b) consolidate the existing care and protection and youth justice independent monitoring and oversight entities into a single entity.

Tūtohi 86 | Recommendation 86

The government should ensure that there are no unreasonable barriers preventing all responsible oversight bodies from investigating complaints, proactively monitoring the care system, and collaborating as appropriate to enable a whole of system view, including:

a) reviewing and addressing any barriers or constraints in the entities’ enabling legislation
b) ensuring the entities are adequately resourced.

Tūtohi 87| Recommendation 87

The responsible oversight bodies should:

a) investigate complaints about care workers, State and faith-based care providers and/or the Care Safe Agency, including both proactive and reactive site visits
b) proactively monitor the way in which State and faith-based care providers and the Care Safe Agency investigate and respond to complaints
c) proactively monitor the care system, including collaboratively to ensure a whole of system view, as appropriate
d) publish reports on their activities including on the outcomes of specific investigations or other monitoring functions
e) share information with the Care Safe Agency, including:

i. data, statistics and other information about the prevalence and nature and extent of abuse and neglect in care
ii. insights about abuse and neglect in care including the effectiveness of different practices to prevent and respond to abuse and neglect in care
iii. refer the results of their investigations and other monitoring functions to enforcement or regulatory bodies including NZ Police, the Charities Commission or the Care Safe Agency.

Ngā whakatau mō Gloriavale
Recommendation about Gloriavale

528. In August 2022, the government established a new function to coordinate the operational activities of government agencies in relation to Gloriavale. Briefings to government released under the Official Information Act in March 2024 noted that this coordinating function came to an end on 31 December 2023.

529. A 20 December 2023 briefing to the Ministers for Workplace Relations and Safety, Education, Social Development and Employment, Police, Children and Women noted that:

“There are several other legal proceedings underway relating to labour exploitation and physical and sexual abuse at Gloriavale, including charges of indecent assault relating to historical offending against young women, against the community’s Overseeing Shepherd Howard Temple. He is currently on bail outside the Gloriavale compound, with a condition of compliance with an Oranga Tamariki safety plan. This includes supervision to prevent any inappropriate contact with a child or young person.

…Oranga Tamariki and Police continue to respond to allegations or disclosures of harm towards children in the community, including those relating to harmful or concerning sexualised behaviour in children.”[272]

530. A briefing to the Minister of Social Development on the same day noted:

“A number of risks and challenges remain… These include risks to child wellbeing, education provision, and risks to the stability of Gloriavale’s commercial enterprises.”[273]

531. The Inquiry is concerned to ensure that the government does everything it can to prevent the factors that led to historical abuse and neglect in care at Gloriavale.

Tūtohi 88 | Recommendation 88

The government should take all practicable steps to ensure the ongoing safety of children, young people and adults in care at Gloriavale.

Footnotes