696. This chapter describes how the recommendations in this report must be implemented.

697. Strong commitment and action is required from everyone in Aotearoa New Zealand to ensure that we can work towards a future where children, young people and adults who need care and support are safe and thrive. This commitment starts with cross-political agreement, which will send a strong message that decision makers are united and clear on the changes needed beyond three-year electoral cycles.

698. To enable participation of survivors and other key parties in this change, it is important that there is a clear action plan for the implementation of recommendations that is collaborative and transparent. It should contain clear accountabilities and enable the public tracking of progress.

Te whakatū Tari Āhuru Mōwai Motuhake hei arataki i te kaupapa
Establishing a Care System Office to lead implementation

699. In the Inquiry’s view, a dedicated government agency is needed to lead the implementation of its recommendations. This will include coordinating with government agencies involved in the care system and with faith-based entities that will be involved in implementing recommendations.

700. This agency needs to have sufficient centrality and seniority to lead and coordinate the care system across the different sectors and settings. It also needs to be independent from the government agencies currently involved in the care system and the people and organisations that have been involved in the government’s response to the Inquiry’s Holistic Redress Recommendations in He Purapura Ora, he Māra Tipu: From Redress to Puretumu Torowhānui.

701. The Inquiry made this same point in He Purapura Ora, he Māra Tipu: From Redress to Puretumu Torowhānui, in relation to setting up an independent entity to run the puretumu torowhānui system and scheme:

“By operating independently, the scheme is much more likely to gain the trust and confidence of survivors. This independence will require the scheme to have no connection with the care institutions or the individuals within them, except as needed to carry out its functions.”[371]

702. The Inquiry recommends that a Care System Office is set up within one of the central agencies (the Treasury, Te Kawa Mataaho Public Service Commission or the Department of the Prime Minister and Cabinet). As discussed in this Part and in Part 7, transforming the way care is delivered requires a whole of government approach. The central agencies work together to ensure the machinery of government operates smoothly. Locating the Care System Office within a central agency would provide leadership and accountability within government and a single, trusted point of engagement for survivors, iwi, hapū and communities.

703. The Care System Office will also be responsible for drafting, and then administering, the Care Safety Act, for establishing the Care Safe Agency and for monitoring its performance on behalf of government and providing whole of system advice to government on the care system. Once the new Act is in place the Inquiry would see the new Care System Office becoming the Ministry for the Care System.

704. The Inquiry envisages that the Care System Office would not be led, or staffed, by senior officials or middle managers who are currently or have been employed by government agencies responsible for delivering and overseeing care including responding to historical claims. As discussed in Recommendations 41–44, this is because many survivors have been traumatised by their interactions with staff and organisations involved in providing care or responding to historical claims and will never be able to trust any system associated with them. In addition, 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.

Tūtohi 123 | Recommendation 123

The government should establish a Care System Office later to become the Ministry for Care System that:

a) is independent from, and has no association with, the government agencies currently involved in the care system (including those involved in historic claims processes and in implementing the Holistic Redress Recommendations in the Inquiry’s interim report He Purapura Ora, he Māra Tipu: From Redress to Puretumu Torowhānui)
b) is set up within one of the central agencies (the Treasury, Te Kawa Mataaho Public Service Commission or the Department of the Prime Minister and Cabinet) as a departmental agency
c) does not employ senior officials or middle management who have been involved in the care system as described in (a) above.

Tūtohi 124 | Recommendation 124

The Care System Office should be responsible for:

a) leading the implementation of the Inquiry’s recommendations set out in this report and the Holistic Redress Recommendations in He Purapura Ora, he Māra Tipu: From Redress to Puretumu Torowhānui
b) leading and coordinating the work of government agencies involved in the care system
c) establishing and then monitoring the independent Care Safe Agency
d) providing advice on the content of the Care Safety Act (Recommendation 45) and then administering the Care Safety Act
e) providing whole of system advice to government on the care sector, settings and system.

Me mahi ngā mea katoa e rite e whai take ai ēnei whakatau
Taking any and all actions needed to give effect to these recommendations

705. The government and faith-based institutions (including indirect care providers) should take any and all actions necessary to implement these recommendations, including changes to:

a. investment
b. public policy
c. legislation or regulations
d. operational practice
e. guidelines.

Tūtohi 125 | Recommendation 125

The government and faith-based institutions should take any and all actions required to give effect to the Inquiry’s recommendations set out in this report and the Holistic Redress Recommendations in He Purapura Ora, he Māra Tipu: From Redress to Puretumu Torowhānui, including changes to investment, public policy, legislation or regulations, operational practice or guidelines.

Te waihanga me te whakatinana i ēnei tūtohinga katoa, e hāngai ai ki te Tiriti o Waitangi, me te Whakaputanga ā te Whakaminenga o te Ao mo ngā iwi taketake, i whai wāhi atu hoki te ringa waihanga o ngā hāpori
Implementation of all recommendations to give effect to te Tiriti o Waitangi and UNDRIP, and be co-designed with communities

706. During the Inquiry period, Māori were denied their tino rangatiratanga and mana by being deprived of the resources and autonomy to care for and raise their whānau who were placed in care. Māori were also excluded from decision-making and influence regarding the design and delivery of the care system. In Part 6, the Inquiry found that the State’s failure to give effect to the preexisting rights it had guaranteed to Māori in te Tiriti o Waitangi had devastating effects on whānau, hapū and iwi and directly contributed to tamariki, rangatahi and pakeke entering care and experiencing abuse and neglect in care.

707. Implementing the recommendations through giving effect to te Tiriti o Waitangi and the United Nations Declaration on the Rights of Indigenous Peoples will ensure that they reflect the needs of Māori and the implementation is tika and pono. It will also lay the foundation for the Inquiry’s vision, in which the State has devolved power, investment and decision-making, so that hapū, iwi and Māori organisations can care for and support their mokopuna and whānau in accordance with their tikanga and mātauranga.

708. The Inquiry expects that in giving effect to te Tiriti o Waitangi and the United Nations Declaration on the Rights of Indigenous Peoples, mātauranga Maori will be given equal importance alongside Western research and knowledge in the design and implementation of the recommendations.

Tūtohi 126 | Recommendation 126

The State and faith-based entities should partner with hapū, iwi and Māori to give effect to te Tiriti o Waitangi and the United Nations Declaration on the Rights of Indigenous Peoples in relation to researching, designing, piloting, implementing and evaluating the Inquiry’s recommendations to ensure that recommendations are implemented in a manner that:

a) reflects the rights, experiences and needs of Māori in care
b) embeds the right to tino rangatiratanga over their kāinga guaranteed to Māori in te Tiriti o Waitangi
c) empowers hapū, iwi and Māori organisations to care for their whānau and implement solutions.

709. The importance of lived experience and co-designing care setting policy and practice with affected communities was not recognised during the Inquiry period.

710. Luamanuvao Dame Winnie Laban told the Inquiry that:

"…there is some goodwill in policy-making agencies but… there's a lack of connection direct with the communities and families that they serve… what needs to happen is there needs to be a greater coherence and listening to what the needs are from our grassroot communities and families so that the policies and responses that are developed meet those needs."[372]

711. The 2018 He Ara Oranga Report of the Government Inquiry into Mental Health and Addiction observed that:

"… at a practice and implementation level, we need to see more examples of genuine co-design processes … in agencies commissioning and delivering services."[373]

712. The Inquiry pictures the level of public participation in the design and implementation of these recommendations operating at the “collaborate/co-design” level on the IAP2 Spectrum of Public Participation. This means that the State and faith-based entities would partner with communities in every aspect of decision-making, including determining the issue/problem, developing solutions, assessing options and making choices.[374]

713. The Inquiry expects that international breakthroughs in treating trauma, including treatment models that lie outside of the Western medical model, will be considered in the design and implementation of the recommendations. Communities will have deep knowledge of best practice relevant to them and should be encouraged to bring this forward in the design and implementation process.

Tūtohi 127 | Recommendation 127

Government and faith-based entities should research, design, pilot, implement and evaluate the Inquiry’s recommendations through co-design with communities, including children, young people and adults in care, survivors, iwi Māori, Pacific Peoples, culturally and linguistically diverse communities, Deaf, disabled people, people who experience mental distress, and Takatāpui, Rainbow and MVPFAFF+ people, to ensure that reforms:

a) reflect the rights, experiences and needs of people in care
b) reflect the diversity of affected communities
c) are tailored to reach, engage and provide access to all communities.

Whakatū kaupapa hautū aronga ako me te whakamātau i te iwi whānui kia mōhio me te ārai i ngā mahi tūkino, whakahāwea, whakaiti tangata
Public awareness and training to prevent abuse and neglect, and address prejudice and discrimination

714. The Inquiry found that ignorance of the signs of abuse and neglect contributed to failures to identify and intervene to prevent abuse and neglect in State and faith-based care during the Inquiry period. Public awareness, education and training about how to prevent, identify and respond to abuse and neglect are critical elements of preventing abuse and neglect in the future. This includes:

a. challenging myths and stereotypes about abusers, bystanders and survivors of abuse and neglect in care
b. helping victims and survivors of abuse and/or neglect, and their whānau and support networks, to minimise shame and self-stigma, recognise the abuse and/or neglect was not their fault and to safely disclose and report as soon as possible
c. understanding what constitutes abuse and neglect
d. recognising the signs of abuse and neglect
e. recognising grooming and other inappropriate behaviours
f. understanding how to respond appropriately to abuse and neglect, including complaints, reports and disclosures.

715. The Inquiry found that survivors of abuse and neglect in State and faith-based care during the Inquiry period experienced discrimination and targeted abuse based on prejudice. The Inquiry also found that social attitudes, ignorance, prejudice and discrimination contributed to people being placed into State and faith-based care and being abused and neglected while in care. The most common forms of prejudice and discrimination seen were:

a. racism, particularly against Māori and Pacific Peoples
b. ableism and disablism, particularly against Deaf, disabled people, and people who experience mental distress
c. sexism against girls and women
d. homophobia and transphobia against Takatāpui, Rainbow and MVPFAFF+ people
e. negative attitudes towards children and young people.

716. A March 2024 report by Mana Mokopuna – the Children and Young Person’s Commission on racism experienced by children and young people noted that:

“Across all of our engagements, mokopuna emphasised that education was a key solution to help eliminate racism in Aotearoa New Zealand.”[375]

717. A 2022 report on the state of disability rights found that “disabled people continue to face widespread discrimination in Aotearoa New Zealand”.[376] A 2023 report on the experiences of Takatāpui and Rainbow rangatahi in care found that “most rangatahi experienced ongoing and normalised transphobic, biphobic, homophobic or interphobic microaggressions while in care.”[377]

718. The Inquiry have a range of recommendations relating to public awareness, training and education programmes, including social and educational campaigns (Recommendation 111), and training and education of NZ Police, investigators, prosecutors, lawyers, and judges (Recommendation 33), staff and care workers (Recommendation 63), and people in religious or pastoral ministry (including clergy, lay people and volunteers) (Recommendation 64).

719. The Inquiry envisages the Care Safe Agency (Recommendation 41) will take a lead role in developing consistent modules on identifying and preventing abuse and neglect in care, and on addressing prejudice and all forms of discrimination, in accordance with its implementation recommendations in Chapter 6.

Tūtohi 128 | Recommendation 128

In implementing all recommendations relating to public awareness and training and education programmes, the government and faith-based entities should ensure that these programmes include:

a) preventing, identifying and responding to abuse and neglect, including:

i. challenging myths and stereotypes about abusers, bystanders and survivors of abuse and neglect in care
ii. helping victims and survivors of abuse and/or neglect, and their whānau and support networks, to minimise shame and self-stigma, recognise the abuse and/or neglect was not their fault and to safely disclose and report as soon as possible
iii. understanding what constitutes abuse and neglect
iv. recognising the signs of abuse and neglect
v. recognising grooming and other inappropriate behaviours
vi. understanding how to respond appropriately to abuse and neglect, including complaints, reports and disclosures

b) addressing prejudice and all forms of discrimination, including:

i. racism
ii. ableism and disablism
iii. sexism
iv. homophobia and transphobia
v. negative attitudes towards children and young people.

Ko ngā kaimahi o tēnei tari me whai pukenga whānui, wheako purapura ora, e hua ai ngā pānga ki te Tiriti o Waitangi
New entity appointments to reflect diversity, survivor experience and give effect to te Tiriti o Waitangi

720. During the Inquiry period, the State lacked diversity and lived experience of care in its leadership and across the public service. This contributed to policy that did not reflect the needs and experiences of people in care.

721. The 2018 He Ara Oranga Report of the Government Inquiry into Mental Health and Addiction noted that “…people with lived experience are too often on the periphery; they should be included in mental health and addiction governance, planning, policy and service development”.[378]

722. The Inquiry also found that Māori were frequently excluded from decision-making and participation in the design and implementation of Crown policy and legislation relating to the care system, as guaranteed in te Tiriti o Waitangi. This was a key finding of the Waitangi Tribunal in their inquiry into Oranga Tamariki.[379] It also noted the ongoing failure of the Crown to “adopt and implement recommendations” of the Puao-te-Ata-Tū Report.[380]

723. Diversity of experience in leadership, governance, staffing and advisory roles ensures that a range of perspectives can inform decision-making and give effect to te Tiriti o Waitangi. Having a range of people with different experiences, competencies and skills also ensures that the new entities will be more flexible, responsive and open to new ideas. This is a key part of enabling good decisions, governance and management that can achieve better outcomes for people in care and their whānau and communities.

Tūtohi 129 | Recommendation 129

The government should ensure, in implementing the recommendations in the Inquiry’s final report and the Holistic Redress Recommendations in He Purapura Ora, he Māra Tipu: From Redress to Puretumu Torowhānui, that appointments to governance and advisory roles:

a) appropriately reflect survivor experience and expertise
b) appropriately and proportionately reflect the diversity of people in care
c) give effect to te Tiriti o Waitangi.

Kia mārama, kia pono ki ngā whāinga tūmatanui e hua ai ngā tūtohinga o tēnei Pakirehua
Transparency and public accountability for implementing the Inquiry’s recommendations

Ko ngā whakahoki kōrero mo ngā whakakitenga me ngā whakatau o te Pakirehua, me whakapuaki tūmatanui i roto i te 6 marama
Responses to the Inquiry’s findings and recommendations must be made publicly available within 6 months

724. To further build trust and promote transparency with survivors, whānau and communities, the government and faith-based institutions must ensure that their responses to the findings and recommendations are published along with their commentary on which findings have been accepted. Where findings have not been accepted, government and faith-based institutions must include commentary explaining why they have not been.

725. The Inquiry envisages that all organisations and entities specified in its recommendations will transparently respond to the recommendations relevant to them.

Tūtohi 130 | Recommendation 130

The government and faith-based institutions should publish their responses to this report and the Inquiry’s interim reports, including whether they accept each of the Inquiry’s findings in whole or in part, and the reasons for any disagreement. The responses should be published within two months of this report being tabled in the House of Representatives.

Tūtohi 131 | Recommendation 131

The government and faith-based institutions should issue formal public responses to this report about whether each recommendation is accepted, accepted in principle, rejected or subject to further consideration. Each response should include a plan for how the accepted recommendations will be implemented, the reasons for rejecting any recommendations, and a timeframe for any further consideration required. Each response should be published within four months of this report being tabled in the House of Representatives.

Me māwhiti i ngā roopu tōrangapū katoa te whakaetanga ki te whakatinana i ngā whakatau
Cross-political party agreement to implement recommendations required

726. During the Inquiry period, despite numerous reports and recommendations to improve the different aspects of care systems and settings, the government’s responses were often piecemeal and reactive. A lack of commitment, transparency and accountability for recommendations has meant that many have not been implemented or they have been superseded by subsequent reports and recommendations.

727. Children, young people and adults in care have the right to be safe from abuse. The changes needed to ensure care in Aotearoa New Zealand is safe are significant and will take time to be effectively implemented. Short-termism and incremental changes have been a barrier to progress in the past and the Inquiry calls on all political parties and policy makers to ensure that this does not inhibit future changes. A significant step has been taken with the completion of this Inquiry, however, there remains a bigger task in implementing the changes needed. Cross-party agreement on the implementation of these recommendations will ensure that, as a nation, we can transform the way we care for children, young people and adults.

Tūtohi 132 | Recommendation 132

The government should seek cross-party agreement to implement this Inquiry’s recommendations.

Te whakamau i ngā kaiwhakatau kaupapa kia ū te tohe e hua ai he tikanga kē
Holding decision-makers to account for ensuring change

728. In Part 7 the Inquiry found there was a consistent lack of accountability for decision makers for their failure to keep people in care safe and to address the systemic causes of abuse in care. There was also a lack of strategic direction and transparency about the piecemeal changes to the care system.

729. The government Child and Youth Wellbeing Strategy 2019 stated that “there are too many policies that were developed and implemented in silos”.[381] A 2024 report from the Independent Children’s Monitor on agency compliance with national care standards found that:

“Our monitoring over the last three years has shown that government agencies do not always work effectively together to support tamariki and rangatahi in care. Particularly in education and health, individual government agency policy settings can sometimes delay or prevent access to services and support.”[382]

730. It is therefore critical to ensure that accountability mechanisms are built into the implementation process for the Inquiry’s recommendations. Public, annual reporting of progress of implementation enables visibility by the public and key parties including survivors. This will support accountability but also allows communities to remain informed of progress and meaningfully participate in the implementation process.

731. The Inquiry recommends the annual reports of all entities implementing the Inquiry’s recommendations are considered by a parliamentary select committee to ensure that there is appropriate parliamentary scrutiny of the implementation of the recommendations.

Tūtohi 133 | Recommendation 133

The government, faith-based institutions and any other agencies that implement the Inquiry’s recommendations should:

a) publicly report on the implementation of the Inquiry’s recommendations contained in the final report and all previous interim reports, including the implementation status of each recommendation and any identified issues and risks
b) publish the implementation report annually for at least 9 years, commencing 12 months after the tabling of this report in the House of Representatives and provide a copy to the Care System Office and Care Safe Agency.

Tūtohi 134 | Recommendation 134

The annual implementation reports should be submitted to and considered by a parliamentary select committee.

He wātaka, he ahunga mahi e tinana ai ngā whakatau o te Pakirehua
Timeframe and approach for the implementation of Inquiry recommendations

732. In the past, regulation of care systems and changes that were made tended to occur without appropriate partnership and collaboration. To ensure that government, faith-based entities and communities across Aotearoa New Zealand can make the transformation needed together, the approach to implementing the Inquiry’s recommendations must be open and transparent. As described in Part 8, the Inquiry is concerned that the government response to He Purapura Ora, he Māra Tipu: From Redress to Puretumu Torowhānui has not been adequately communicated to survivors and stakeholders, and progress has stalled. Aotearoa New Zealand cannot afford to delay action any longer.

733. As discussed in Chapter 3, the Inquiry foresees at least three phases of work on the pathway to realising he Māra Tipu between now and 2040:

a. Phase 1 (2024–2030): Implementing the Inquiry’s recommendations and consolidating change
b. Phase 2 (2031): Review Phase 1 and implement next steps towards he Māra Tipu
c. Phase 3 (2032–2040): Review Phase 2 and implement final next steps towards he Māra Tipu

734. Chapter 9 sets out the Inquiry’s recommended approach to implementation timeframes, including the leading or coordinating entity or entities.

Tūtohi 135 | Recommendation 135

The government and faith-based entities should implement the Inquiry’s recommendations in line with the timeframes described in this report, whilst ensuring there is open and transparent communication with communities with whom they are co-designing the future arrangements for care.

Te arotakenga motuhake mo te whakatinanatanga o ngā whakatau o te Pakirehua, me tīmata i roto i te 9 tau
Independent review of implementation of Inquiry’s recommendations to be initiated in 9 years

735. As discussed in Chapter 3, the Inquiry recommends three stages of work to implement the Inquiry’s recommendations and achieve He Māra Tipu. After the recommendations are implemented and consolidated (Phase 1 and 2), Phase 3 will involve reviewing and deciding on next steps.

736. This consists of a pause and reassessment – where the State, faith-based institutions, people in care, whānau and communities come together and consider progress and the next steps that are needed to progress to He Māra Tipu.

737. An independent review should be undertaken seven years after the tabling of this report. It needs to be independent to ensure there is objective scrutiny of progress. It is also critical there is an open process where survivors, non-government organisations, hāpori Māori, iwi and hapū, Te Kāhui Tika Tangata Human Rights Commission and other significant bodies can make submissions to the review panel.

738. It will require the scrutiny of a parliamentary select committee, and State and faith-based institutions should publish formal responses to the review. This will enable transparency about how each setting will address recommendations and the next steps to progress to He Māra Tipu.

Tūtohi 136 | Recommendation 136

The government should initiate an independent review to be completed by 9 years after the tabling of the final report. This review should:

a) establish the extent to which the Inquiry’s recommendations have been implemented 9 years after the tabling of the final report
b) examine the extent to which the measures taken in response to the Inquiry have been effective in preventing abuse and neglect in care, improving the responses of all entities providing care directly or indirectly to abuse and neglect in care and ensuring that victims and survivors of abuse and neglect in care obtain justice, treatment and support
c) advise on what further steps should be taken by governments and all entities providing care directly or indirectly to ensure continuing improvement in policy and service delivery in relation to abuse and neglect in care.

Tūtohi 137 | Recommendation 137

The government’s implementation reports, and the independent 9-year review should be tabled in the House of Representatives and referred to a parliamentary select committee for consideration.

Tūtohi 138 | Recommendation 138

The government and faith-based institutions should publish formal responses to the independent 9-year review, indicating whether its advice on further steps is accepted, accepted in principle, rejected or subject to further consideration. Each response should include a plan for how the accepted recommendations will be implemented, the reasons for rejecting any recommendations, and a timeframe for any further consideration required. Each response should be published by 31 December 2033.