Recommendation 1: Implement the new puretumu torowhānui system and scheme as an immediate priority
Tūtohi 1: He hautū i te pūnaha puretumu torowhānui hei kaupapa matua, ināia tonu ne

Tūtohi | Recommendation 1

As an immediate priority, the government and faith-based institutions should implement the 95 recommendations in the Inquiry’s interim report on redress, He Purapura Ora, he Māra Tipu: From Redress to Puretumu Torowhānui (2021), together with the recommendations of the design group, subject to any further recommendations made in this report.

Recommendations 2–4: Key leaders to make public acknowledgements and apologies
Ngā tūtohi 2–4: Kia puta he tohu me te reo whakapahā tūmatawhānui i ngā kaitaki matua

Tūtohi | Recommendation 2

The Prime Minister should make a national apology for historical abuse and neglect in the care of the State (both direct and indirectly) in the House of Representatives. The national apology should:

a. be developed and agreed with a representative group of survivors
b. be consistent with the puretumu torowhānui system and scheme and the Recommendations from the Inquiry’s interim report, He Purapura Ora, he Māra Tipu: From Redress to Puretumu Torowhānui (2021)
c. apologise to all survivors of abuse and neglect in State-based care (both direct and indirect care), and include specific apologies to:

i. the many who suffered abuse and neglect that have died and are no longer able to share their experiences and acknowledge them and their whānau, hapū, iwi, communities and support networks
ii. Māori survivors, their whānau, hapū, iwi, communities and support networks
iii. Pacific survivors, their kainga, communities and support networks
iv. Deaf survivors, their whānau, hapū, iwi, communities and support networks
v. disabled survivors, their whānau, hapū, iwi, communities and support networks
vi. Pākehā / NZ European survivors, their family, communities and support networks
vii. survivors who experienced mental distress, their whānau, hapū, iwi, communities and support networks
viii. Takatāpui, Rainbow, MVPFAFF+ survivors, their whānau, hapū, iwi, communities and support networks

d. as outlined in He Purapura Ora, he Māra Tipu: From Redress to Puretumu Torowhānui (2021), make a specific apology to groups who were harmed, including Māori, where appropriate.

Tūtohi | Recommendation 3

Public acknowledgments and apologies for historical abuse and neglect in the care of the State (both direct and indirectly provided care) and faith-based institutions should be made to survivors, their whānau and support networks by:

a. the most senior leaders of all faith-based institutions and in particular, and without limitation:

i. the Pope should make a public apology and acknowledgement for the abuse and neglect in the care of the Catholic Church in Aotearoa New Zealand
ii. the Archbishop of Canterbury should make a public apology and acknowledgement for the abuse and neglect in the care of the Anglican Church in Aotearoa New Zealand and Polynesia
iii. the President Elect should make a public apology and acknowledgement for the abuse and neglect in the care of the Methodist Church in Aotearoa
iv. the Moderator of the Presbyterian Church of Aotearoa New Zealand should make a public apology and acknowledgement for the abuse and neglect in the care of the Presbyterian Church of New Zealand
v. the Chief Executive Officer (or equivalent) of each individual Presbyterian Support Organisation should make public apologies and acknowledgements for abuse and neglect in the care of their respective Presbyterian Support organisation
vi. the General of The Salvation Army should make a public apology and acknowledgement for the abuse and neglect in the care of The Salvation Army of New Zealand, Fiji, Tonga and Samoa Territory
vii. the Overseeing Shepherd should make a public apology and acknowledgement for the abuse and neglect in the care of Gloriavale Christian Community
viii. the Governing Body of Jehovah’s Witnesses should make a public apology and acknowledgement for the abuse and neglect in the care of Jehovah’s Witnesses in New Zealand.

b. public sector leaders, including the Public Service Commissioner, Solicitor-General, Commissioner of NZ Police and the Chief Executives of Oranga Tamariki, the Ministry of Social Development, the Ministry of Health, and the Ministry of Education
c. the leaders of relevant professional bodies, including the Royal Australian and New Zealand College of Psychiatrists, Medical Council of New Zealand, Aotearoa New Zealand Association of Social Workers, New Zealand Nurses Association, Teaching Council of Aotearoa New Zealand
d. the leaders of all direct and indirect care providers, including Blind Low Vision NZ and IHC.
Each public apology should be:
e. developed and agreed with a representative group of survivors
f. be consistent with the puretumu torowhānui system and scheme and the Holistic Redress Recommendations from the Inquiry’s interim report, He Purapura Ora, he Māra Tipu: From Redress to Puretumu Torowhānui.

Tūtohi | Recommendation 4

The Catholic Church’s principal representative in Aotearoa New Zealand, the Archbishop of Wellington and eighth ordinary of the see, should write to the Pope and the Congregation for the Institutes of Consecrated Life and Societies of Apostolic Life:

a. expressing concern that brothers in the Hospitaller Order of the Brothers of St John of God who have been accused or convicted of sexual abuse and neglect in Australia and Aotearoa New Zealand have also been sent to Papua New Guinea, and little is known about the nature and extent of abuse and neglect there or the needs of potential survivors
b. seeking an Apostolic visitation into the nature and extent of abuse and neglect by the Order in Papua New Guinea and the systemic factors leading to abuse and neglect by the Order in the Oceania province.

The letter should be developed and agreed with a representative group of survivors. The letter and report from the Pope and the Congregation for the Institutes of Consecrated Life and Societies of Apostolic Life should be made public.

Recommendation 5: Review the appropriateness of street names, public amenities named after a proven perpetrator
Tūtohi 5: Kia tirohia anō te tika o te whakahua ingoa huarahi, kaupapa tūmatawhānui rānei, kua tohia mo tētahi kaitūkino kua kitea i te hē

Tūtohi | Recommendation 5

All entities that provide care, or have provided care, directly or indirectly on behalf of the State and faith-based entities, local authorities and any other relevant entities should:

a. review the appropriateness of any streets, public amenities, public honours or any memorials named after, depicting, recognising or celebrating a proven perpetrator of abuse and neglect in care and /or an institution where proven abuse and neglect took place
b. consider what steps may be taken to change the names and what else should be done address the harm caused to survivors by the memorialisation of proven perpetrators and institutions where abuse and neglect took place.

Recommendations 6–7: Take steps to determine liability for torture, or cruel, inhuman, or degrading treatment or punishment
Ngā tūtohi 6–7: He whakatau kawengā-ā-hara mo tētahi i ngā mahi tūkino, parahako, patu tāngata rānei

Tūtohi | Recommendation 6

Where there are reasonable grounds to believe that torture or cruel, inhuman or degrading treatment or punishment have occurred in care directly or indirectly on behalf of the State or faith-based entities, and the relevant allegations have not been investigated by NZ Police or credible new information has arisen since the allegations were investigated, NZ Police should:
a. open or re-open independent and transparent criminal investigations into possible criminal offending
b. proactively and widely advertise the intent to investigate and ongoing investigations
c. provide appropriate assistance and support to survivors, their whānau and support networks who contact them in relation to the investigations.

Tūtohi | Recommendation 7

Where there are reasonable grounds to believe that torture, or cruel, inhuman, or degrading treatment or punishment have occurred in care, the State, faith-based institutions and indirect care providers should:

a. provide reasonable assistance to any NZ Police investigation
b. take all reasonable steps to ensure an impartial and independent investigation is carried out by an appropriate investigator
c. if there is credible evidence of breaches of the law (including breaches of human rights), ensure that appropriate redress is provided to the survivors, consistent with applicable domestic and /or international obligations
d. use best endeavors to have the liability of every relevant institution in relation to such acts determined. This may include:

i. seeking opinions from King’s Counsel, which are then shared with relevant survivors, on the nature of the conduct and the liability of relevant institutions, including as applicable under the New Zealand Bill of Rights Act 1990. Consideration may also be given to seeking declaratory judgments from the courts. Survivors should be fully supported to take part in these initiatives, including with funding for legal and other expenses
ii. not pleading limitation defences in cases brought by survivors, for as long as limitation defences remain available.

Recommendations 8–9: Ensure faith-based institutions and indirect State care providers join the puretumu torowhānui system and scheme
Ngā tūtohi 8–9: He tohe tonu i ngā kaitiaki kaupapa-ā-whakapono me te hunga kaitiaki kei waho i ngā kaupapa kāwanatanga kia uru ki raro i te kaupapa pūnaha puretumu torowhānui

Tūtohi | Recommendation 8

The government should take all practicable steps, including incentives and, if necessary, compulsion, to ensure that faith-based institutions and indirect care providers join the puretumu torowhānui system and scheme once it is established.

Tūtohi | Recommendation 9

Representatives of faith-based institutions and indirect care providers should meet with relevant State representatives and agree on what steps they can take, whether separately or together, to ensure that survivors, their whānau and support networks are made aware of the puretumu torowhānui system and scheme and support options available to them.

Recommendation 10: Backdate eligibility for the puretumu torowhānui system and scheme to December 2021
Tūtohi 10: He whakahoki i te mana o te kaupapa pūnaha puretumu torowhānui mai i te Tīhema 2021

Tūtohi | Recommendation 10

The government and faith-based institutions should ensure that, once the puretumu torowhānui system and scheme is established:

a. the effective start date for the system and scheme is 1 December 2021, to enable the whānau of survivors who have died since that date to be eligible for redress claims and the full range of support services available through the system and scheme
b. it is open to all survivors, including those who have been through all redress processes (including those that have been completed since 1 December 2021) whether or not any signed settlement agreement was full and final.

Recommendation 11: Compensate survivors of abuse and neglect in care
Tūtohi 11: Me whakatau he utu ki ngā purapura ora i pākia e ngā mahi tūkino i roto i ngā pūnaha taurima

Tūtohi | Recommendation 11

If the government does not progress the Inquiry’s recommended civil litigation reforms (Holistic Redress Recommendations 75 and 78 from the Inquiry’s interim report, He Purapura Ora, he Māra Tipu: From Redress to Puretumu Torowhānui):

a. the government should reform the accident compensation (ACC) scheme to provide tailored compensation for survivors of abuse and neglect in care and other appropriate remedies
b. survivors should be fairly and meaningfully compensated for all direct and indirect losses flowing from the abuse and neglect they experienced in care and that are covered by the new puretumu torowhānui system and scheme
c. the application process should be survivor-focused, trauma-informed and delivered in a culturally and linguistically appropriate manner.

Recommendations 12–13: Order of the Brothers of St John of God specific actions
Ngā tūtohi 12–13: He whakatau motuhake mō te Order of St John of God

Tūtohi | Recommendation 12

The Bishop of the Diocese of Christchurch should write to the Provincial of the Oceania Province of the St John of God Brothers seeking:

a. regular notifications of all new reports of abuse and neglect in Aotearoa New Zealand received by the Order of the Brothers of St John of God (subject to complainants’ consent)
b. regular notifications of all requests to reopen or reassess claims involving Aotearoa New Zealand survivors
c. the Order’s response to all such reports and requests.

All correspondence should be made public, together with an explanation of the steps taken in response as soon as possible.

Tūtohi | Recommendation 13

The Bishop of Christchurch, the Provincial of the Oceania Province of the St John of God Brothers and relevant State representatives should meet and agree on what steps they can take, whether separately or together, to ensure all survivors of Marylands School, St Joseph’s Orphanage and Hebron Trust in Ōtautahi Christchurch and their whānau or support networks are made aware of the puretumu torowhānui system and scheme and support options available to them.

Recommendation 14: Give effect to te Tiriti o Waitangi in the puretumu torowhānui system and scheme
Tūtohi 14: He whakamana i te Tiriti o Waitangi ki roto i te kaupapa pūnaha puretumu torowhānui

Tūtohi | Recommendation 14

The government should ensure that the puretumu torowhānui system and scheme is designed and operated in a manner that gives effect to te Tiriti o Waitangi and its principles.

Recommendations 15–17: Embed human rights into the puretumu torowhānui system and scheme
Ngā tūtohi 15–17: He whakatō i ngā mōtika tangata ki roto i te kaupapa pūnaha puretumu torowhānui

Tūtohi | Recommendation 15

The government should ensure that the puretumu torowhānui system and scheme is designed and operated in a manner consistent with:

a. upholding the rights of Māori as indigenous peoples of Aotearoa New Zealand in accordance with United Nations Declaration on the Rights of Indigenous Peoples
b. upholding the rights of Māori, Pacific Peoples, and people from other linguistically or culturally diverse backgrounds, in accordance with the Convention on the Elimination of all forms of Racial Discrimination
c. upholding the rights of girls and women, in accordance with the Convention on the Elimination of All Forms of Discrimination against Women
d. upholding the rights of Deaf, disabled people, and people who experience mental distress, in accordance with the Convention on the Rights of Persons with Disabilities and the Enabling Good Lives principles, including:

i. recognition that Deaf, disabled people, and people who experience mental distress in care have:

• • • • • • • • • • the same rights as others to make decisions that affect them, including adults having decision-making supports as appropriate
                  • the right to access and use supports (including communication assistance) in making and participating in decisions that affect them, communicating their will and preferences, and developing their decision-making ability
                  • access and use advocacy services in making and participating in decisions, and communicating their will and preferences

ii. recognition that tāngata Turi, tāngata whaikaha and tāngata whaiora Māori and Pacific survivors who are Deaf, disabled, or experience mental distress, survivors from other culturally or linguistically diverse backgrounds, and Takatāpui, Rainbow and MVPFAFF+ survivors may experience barriers to engaging with the system and scheme due to cultural, language and other differences, and that these barriers need to be addressed

e. upholding the rights of children, and ensuring that all parties involved in the design and operation of the system and scheme:

i. act with the best interests of the child as a primary consideration, consistent with the United Nations Convention on the Rights of the Child
ii. recognise the rights of iwi, hapū and whānau Māori to retain shared responsibility for the wellbeing of tamariki and rangatahi Māori, consistent with the United Nations Declaration on the Rights of Indigenous Peoples.

Tūtohi | Recommendation 16

The government should establish performance indicators for the puretumu torowhānui system and scheme, based on New Zealand’s domestic and international obligations including te Tiriti o Waitangi and taking into account guidance from the Office of the United Nations High Commissioner for Human Rights.

Tūtohi | Recommendation 17

The government should regularly assess the puretumu torowhānui system and scheme against the performance indicators and publish annual reports on progress against the indicators.

Recommendation 18: Review Lake Alice settlements for parity
Tūtohi 18: Tirohia anō mehemea kei te ōrite ngā whakatau mō Lake Alice

Tūtohi | Recommendation 18

The government should:

a. appoint an independent person to promptly review all Lake Alice settlements and advise whether any further payments to claimants who have previously settled are necessary to ensure parity in light of the District Court decision in 2002 regarding the deduction of money from second round claimants for legal costs
b. ensure that any payments to claimants who have not yet settled are, as a minimum, equitable in light of the review.

Recommendation 19: Establish an independent investigation of unmarked graves and urupā
Tūtohi 19: Whakatūria he arotakenga motuhake mō ngā poka ingoa kore me ngā urupā

Tūtohi | Recommendation 19

The government should appoint and fund an independent advisory group to investigate potential unmarked graves and urupā at the sites of former psychiatric and psychopaedic hospitals, social welfare institutions or other relevant sites.

Recommendation 20: Establish a fund for projects connected to community harm arising from the cumulative impact of abuse and neglect in care
Tūtohi 20: Whakatū tahua pūtea mo ngā kaupapa e hāngai ana ki ngā parurenga i hua ake i ngā mahi tūkino katoa i pā ki te hunga i roto i ngā pūnaha taurima

Tūtohi | Recommendation 20

The government and faith-based institutions should jointly establish a fund to provide contestable funding for projects that promote effective community healing from the collective impacts of abuse and neglect in care, like those established in Canada and Australia. The entity holding and distributing the funding should be independent from State and faith-based entities.

Recommendation 21: Whānau payments for whānau of survivors of abuse and neglect in care
Tūtohi 21: He utua ā whānau ki ngā whānau purapura ora

Tūtohi | Recommendation 21

Recognising the intergenerational damage caused by abuse in care, the Inquiry recommends that a whānau harm payment be provided for members of whānau who have been cared for by survivors and thereby potentially impacted by their tūkino, to help prevent further intergenerational harm. The Inquiry recommends this is set at $10,000.

Recommendations 22–24: Amend prosecution guidelines
Ngā tūhoi 22–24: Panonihia ngā tikanga whakawhiu-ā-ture

Tūtohi | Recommendation 22

The Solicitor-General should amend the suite of prosecution guidelines to:

a. include a requirement that those making decisions about whether to prosecute, and which charges to file, act consistently with New Zealand’s international human rights obligations and other relevant international law obligations (including the United Nations Convention on the Rights of Persons with Disabilities, the United Nations Convention on the Rights of the Child and the United Nations Declaration on the Rights of Indigenous Peoples)
b. include, in relation to the evidential test for prosecution, a requirement that those making assessments on the credibility and quality of a complainant’s evidence recognise the potential for their own bias, obtain relevant expert advice where necessary, and provide appropriate accommodations where necessary
c. include, as a public interest consideration for prosecution, that the offence was committed against a person in the care of the State or a faith-based institution
d. strengthen obligations to engage appropriately (that is, more than consult) with complainants (including the use of communication assistance) on prosecution decisions, including when considering whether to prosecute because of the likely detrimental effect on a witness’s physical or mental health
e. establish a review process for complainants who allege offences falling under Parts 7 or 8 of the Crimes Act 1961 where a decision has been made not to prosecute by NZ Police or a Crown Solicitor, which:

i. is designed to ensure fairness and consistency in approach to charging decisions nationwide
ii. requires an evaluative review of the evidence and the decision not to prosecute
iii. establishes national panels of suitably trained and experienced prosecutors to conduct reviews of decisions not to prosecute made by NZ Police and Crown Solicitors
iv. includes a requirement for the panel reviewing NZ Police decisions not to prosecute to seek legal advice from a Crown Solicitor where the decision is finely balanced and /or complex, or is an offence listed in the schedule to the Crown Prosecution Regulations 2013
v. has the power to refer a decision not to prosecute back to the decision maker for further consideration and /or investigation
vi. ensures complainants are consulted in person with necessary accommodations.

Tūtohi | Recommendation 23

The Solicitor-General should issue specific guidelines to prosecutors on how to approach cases involving complainants, witnesses and defendants who are Deaf, disabled and /or experience mental distress to ensure access to justice, and in doing so should involve those with lived experience throughout the development process to ensure concerns and aspirations are consistently understood and considered.

Tūtohi | Recommendation 24

The government should invest in training for prosecutors on these guidelines.

Recommendation 25: Support judicial initiatives that address the causes of offending
Tūtohi 25: Tautokohia ngā tikanga-ā-ture e tohu ana ki ngā take whakamau hara

Tūtohi | Recommendation 25

The government should support and invest in judicial-led initiatives, such as Te Ao Mārama – Enhancing Justice for All, that recognise and address the harm caused by abuse and /or neglect in care.

Recommendations 26–32: Criminal justice legislative changes
Ngā tūtohi 26–32: Ngā panoni ture taihara

Tūtohi | Recommendation 26

The government should amend the Crimes Act 1961 to specifically include disability within the definition of a vulnerable adult.

Tūtohi | Recommendation 27

The government should amend the Sentencing Act 2002 to:

a. include, as an aggravating feature in section 9(1), the fact that a victim was particularly vulnerable arising from being in State or faith-based care or deprived of liberty
b. expand the requirement for the court to consider the aggravating factors in section 9A(2) in cases of abuse and /or neglect to include children and young persons under the age of 18 years
c. include a requirement that when considering an offender’s previous convictions under section 9(1)(j) the court should ensure those with convictions for offences committed in response to abuse and/or neglect in care are not unduly penalised.

Tūtohi | Recommendation 28

The government should amend section 284 of the Oranga Tamariki Act 1989 to ensure that offending by young people abused and /or neglected in care in response to that abuse and/or neglect, is not given undue weight as an aggravating factor at sentencing for later unrelated offending.

Tūtohi | Recommendation 29

The government should review the Criminal Records (Clean Slate) Act 2004 to ensure that offending committed by people abused and /or neglected in care in response to that abuse or neglect, does not unfairly exclude them from eligibility under the Act.

Tūtohi | Recommendation 30

The government should amend section 11 of the Victims Rights Act 2002 to ensure that victims of abuse and neglect in State or faith-based care must be advised of the ability to seek redress in the civil courts and through the puretumu torowhānui system and scheme, and their right to apply for legal aid for civil proceedings.

Tūtohi | Recommendation 31

The Ministry of Justice should establish a list of specialist lawyers available to provide legal advice to victims about seeking puretumu torowhānui (holistic redress).

Tūtohi | Recommendation 32

The government should amend section 80(3) of the Evidence Act 2006 to ensure witnesses in criminal proceedings have an entitlement to apply for communication assistance to enable them to both understand the proceedings and to give evidence.

Recommendation 33: Education and training for people involved in the justice system
Tūtohi 33: Te ako me te whakamatautau i te hunga e mahi ana i roto i te pūnaha-ā-ture

Tūtohi | Recommendation 33

The Ministry of Justice, Te Kura Kaiwhakawā Institute of Judicial Studies, NZ Police, the Crown Law Office, the New Zealand Law Society and other relevant legal professional bodies should ensure that investigators, prosecutors, lawyers, and judges receive education and training from relevant subject matter experts on:

a. the Inquiry’s findings, including on the nature and extent of abuse and neglect in care, the pathway from care to custody, and the particular impacts on survivors of abuse and neglect experienced in care
b. trauma-informed investigative and prosecution processes
c. all forms of discrimination
d. engaging with neurodivergent people
e. human rights concepts, including the obligations under the Convention on the Rights of Persons with Disabilities, the Convention on the Rights of the Child, Convention on the Elimination of All Forms of Discrimination against Women, Convention on the Elimination of all forms of Racial Discrimination, and the United Nations Declaration on the Rights of Indigenous Peoples.

Recommendations 34–35: Amend investigation guidelines and establish a specialist investigation unit
Ngā tūhoi 34–35: Panonihia ngā kaupapa arotake, ka whakatū ai he tira wherawhera motuhake

Tūtohi | Recommendation 34

NZ Police should review the Police Manual and other relevant material to ensure instructions and guidelines reflect and refer to Aotearoa New Zealand’s international human rights obligations and other relevant international law obligations (including the Convention on the Rights of Persons with Disabilities, the Convention on the Rights of the Child, Convention on the Elimination of All Forms of Discrimination against Women, Convention on the Elimination of all forms of Racial Discrimination, and the United Nations Declaration on the Rights of Indigenous Peoples).

Tūtohi | Recommendation 35

NZ Police should establish a specialist unit dedicated to investigating and prosecuting those responsible for historical or current abuse and neglect in State and faith-based care.

Recommendations 36–38: Civil justice legislative changes
Ngā tūtohi 36–38: Ngā panoni ture tikanga-ā-iwi

Tūtohi | Recommendation 36

The courts should prioritise civil proceedings regarding care or abuse and neglect in State or faith-based care to minimise litigation delays.

Tūtohi | Recommendation 37

The government should review the Legal Services Act 2011 to remove barriers to civil proceedings regarding abuse and neglect in care, including means-testing criteria, charges over property, and repayments.

Tūtohi | Recommendation 38

The government should amend the following provisions of the Evidence Act 2006:

a. section 80(3), to ensure that witnesses in civil proceedings have an entitlement to apply for communication assistance to enable them to understand the proceedings and give evidence
b. section 103(4)(b)(ii), to require a court when making directions on alternative ways of giving evidence in civil proceedings relating abuse and neglect in care to consider the need to promote the recovery of parties and witnesses from the abuse and neglect
c. subpart 5, to include provision for directions for alternative ways of giving evidence for parties and witnesses in civil proceedings where appropriate.

Recommendation 39: Principles for preventing and responding to abuse and neglect in care
Tūtohi 39: Ngā mātāpono hei ārai, hei tiaki i te hunga kei tūkinohia i ngā pūnaha taurima

Tūtohi | 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 need 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, the Enabling Good Lives principles, and recognise and provide for diverse needs including Deaf, disabled people, and people experiencing mental distress:

i. people in care are supported and provided accessible information to 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, safety of people in care and 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 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, decision-making supports to engage in complaints processes
ii. care providers have complaint handling policies appropriate for the people in care which 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 whilst upholding the right to privacy and ensuring 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, 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.

Recommendation 40: National Care Safety Strategy
Tūtohi 40: He Rautaki Āhuru Mōwai-ā-Motu

Tūtohi | 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, 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.

Recommendations 41–44: Establishing an independent Care Safe Agency
Ngā tūtohi 41–44: Te whakatū Tira Āhuru Mōwai Motuhake

Tūtohi | 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 sanction 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 of Part 9.

Tūtohi | 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 | 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.

Tūtohi | 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.

Recommendations 45–46: Establishing a new Care Safety Act
Ngā tūtohi 45–46: Te hanga Ture Āhuru Mōwai

Tūtohi | 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 rcommendations, 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 | 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.

Recommendation 47: Consistent and comprehensive care safety standards and penalties for non-compliance
Tūtohi 47: Te waihanga raupapa āhuru mōwai whānui me ngā whiu mo te kore e hāngai

Tūtohi | 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.

Recommendations 48–56: Care providers to be accredited and prioritise safeguarding
Ngā tuhoi 48–56: He whakamana i te hunga kaitiaki me ngā tikanga noho āhuru matua

Tūtohi | 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.

Tūtohi | 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.

Tūtohi | 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 | 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 | 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 | 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 | 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.

Tūtohi | 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 | 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.

Recommendations 57–64: Staff and care workers to be vetted, registered, and well trained
Ngā tūtohi 57–64: Ngā kaimahi me ngā kaitiaki, kia tōtika, kia āta wherawherahia, me rēhita, me tautoko, kia tika te ako

Tūtohi | 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.

Tūtohi | 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 | 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 | 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.

Tūtohi | 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 the 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 | 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.

Tūtohi | 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 how to protect children, young people and adults in care from abuse and neglect and respond to disclosures
j. there are no adverse employment or other consequences for those making good faith notifications or disclosures of abuse and neglect.

Tūtohi | 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, and in particular, faith-based entities should ensure the same rules apply to people in religious ministry and lay volunteers as to employees.

Recommendations 65–69: Complaints are responded to effectively
Ngā tūtohi 65–69: Kia tika te whakaea i ngā tautohenga

Tūtohi | 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 are 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 Peoples, 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 Safety 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.

Tūtohi | 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.

Tūtohi | 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 | 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.

Tūtohi | 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.

Recommendations 70–75: Institutional environments and practices to be minimised and ultimately eliminated
Ngā tūtohi 70–75: Ngā wahi tiaki me ōna tikanga kia iti iho te mana, kia kore rawa atu rānei a tōna wa

Tūtohi | 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 historic abuse and neglect in care.

Tūtohi | 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.

Tūtohi | 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 | 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.

Tūtohi | 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.

Tūtohi | 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.

Recommendations 76–80: People in care are empowered and supported
Ngā tūtohi 76–80: Me whakamana, me tautoko te hunga kei ngā pūnaha taurima

Tūtohi | 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 their 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 | Recommendation 77

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

Tūtohi | 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.

Tūtohi | 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 | 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.

Recommendations 81–84: Best practice data collection, record keeping and information sharing
Ngā tūtohi 81–84: Kia tōtika ngā kohinga me ngā tukunga raraunga, me ngā tuhinga kōrero

Tūtohi | 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 or 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 or 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 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 | 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 | 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.

Tūtohi | 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 consider 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.

Recommendations 85–87: Independent oversight and monitoring is coherent and well-resourced
Ngā tūtohi 85–87: He taurite me te whai rawa i ngā mahi aroturuki motuhake

Tūtohi | 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 | 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 | 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.

Recommendation 88: Recommendation about Gloriavale
Tūtohi 88: Ngā whakatau mo Gloriavale

Tūtohi | Recommendation 88

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

Recommendations 89–110: Recommendations to all faith-based entities providing care in Aotearoa New Zealand 
Ngā tūtohi 89–110: Ngā whakatau e hāngai ana ki te katoa o ngā tira whakapono o Aotearoa e whakarato tiaki

Tūtohi | Recommendation 89

All faith-based entities that provide activities or services of any kind, under the auspices of a particular religious denomination or faith, through which adults have contact with children, young people or adults in care, should comply with 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. Faith-based entities in highly regulated sectors, such as schools and out-of-home care service providers, should also report their compliance to the religious organisation to which they are affiliated.

Tūtohi | Recommendation 90

All faith-based entities should adopt the Care Safety Principles (Recommendation 39), the National Care Safety Strategy (Recommendation 40) and all statutory requirements under the Care Safety Act (Recommendation 41), including care standards, accreditation, and vetting, for each of their affiliated institutions.

Tūtohi | Recommendation 91

All faith-based entities should drive a consistent approach to the implementation of the Care Safety Principles (Recommendation 39), the National Care Safety Strategy (Recommendation 40) and all statutory requirements under the Care Safety Act (Recommendation 41), including care standards, accreditation, and vetting, in each of their affiliated institutions.

Tūtohi | Recommendation 92

All faith-based entities should work closely with the independent Care Safe Agency and independent oversight bodies to support the implementation of and compliance with the Care Safety Principles (Recommendation 39), the National Care Safety Strategy (Recommendation 40), and all statutory requirements under the Care Safety Act (Recommendation 41), including care standards, accreditation, and vetting, in each of their affiliated institutions.

Tūtohi | Recommendation 93

All faith-based entities should ensure their religious leaders are provided with leadership training both pre- and post-appointment, including identifying, preventing, and responding to abuse and neglect in care, cultural awareness, and addressing prejudice and all forms of discrimination.

Tūtohi | Recommendation 94

All faith-based entities should ensure that religious leaders are accountable to an appropriate authority or body, such as a board of management or council, for the decisions they make with respect to preventing and responding to abuse and neglect in care.

Tūtohi | Recommendation 95

All faith-based entities should ensure that all people in religious or pastoral ministry, including religious leaders, are subject to effective management and oversight and undertake annual performance appraisals.

Tūtohi | Recommendation 96

All faith-based entities should ensure that all people in religious or pastoral ministry, including religious leaders, have professional supervision with a trained professional or pastoral supervisor who has a degree of independence from the institution within which the person is in ministry.

Tūtohi | Recommendation 97

Each faith-based entity should have a policy relating to the management of actual or perceived conflicts of interest that may arise in relation to allegations of abuse and neglect in care. The policy should cover all individuals who have a role in responding to complaints of abuse and neglect in care.

Tūtohi | Recommendation 98

Each faith-based entity should ensure that candidates for religious ministry undertake minimum training on preventing and responding to abuse and neglect in care and related matters, including training that:

a. equips candidates with an understanding of 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
b. educates candidates on:

i. professional responsibility, boundaries and ethics in ministry
ii. identifying and preventing abuse and neglect in care
iii. cultural awareness
iv. addressing prejudice and all forms of discrimination
v. policies regarding appropriate responses to allegations or complaints of abuse and neglect in care, and how to implement these policies
vi. how to work with children, young people, and adults in care.

Tūtohi | Recommendation 99

Each faith-based entity should require that all people in religious or pastoral ministry, including religious leaders, undertake regular training on the institution’s safeguarding policies and procedures. They should also be provided with opportunities for external training on best practice approaches to people safety.

Tūtohi | Recommendation 100

Wherever a faith-based entity has children, young people, or adults in its care, they should be provided with age-appropriate prevention education that aims to increase their knowledge of abuse and neglect and build practical skills to assist in strengthening self-protective skills and strategies. Prevention education in religious institutions should specifically address the power and status of people in religious ministry and educate children, young people, and adults in care that no one has a right to invade their privacy and make them feel unsafe.

Tūtohi | Recommendation 101

All faith-based entities should revise their policies to reduce high barriers to disclosure including through flexibility for disclosures of abuse.

Tūtohi | Recommendation 102

Each faith-based entity should make provision for family and community involvement by publishing all policies relevant to preventing and responding to abuse and neglect in care on its website, providing opportunities for comment, and seeking periodic feedback about the effectiveness of its approach to preventing and responding to abuse and neglect in care.

Tūtohi | Recommendation 103

All faith-based entities’ complaint handling policies should require that, upon receiving a complaint of abuse and neglect in care, an initial risk assessment is conducted to identify and minimise any risks to children, young people, and adults in care.

Tūtohi | Recommendation 104

All faith-based entities’ complaint handling policies should require that, if a complaint of abuse and neglect in care against a person in religious ministry is credible, and there is a risk that person may come into contact with children in the course of their ministry, the person be stood down from ministry while the complaint is investigated.

Tūtohi | Recommendation 105

All faith-based entities should, when deciding whether a complaint of abuse and neglect in care has been substantiated, consider the principles set out by the courts in applicable case law in accordance with the seriousness of the allegation.[1]

Tūtohi | Recommendation 106

All faith-based entities should apply the same standards for investigating complaints of abuse and neglect in care, whether or not the subject of the complaint is a person in religious ministry.

Tūtohi | Recommendation 107

Any person in religious ministry who is the subject of a complaint of abuse and neglect in care which is substantiated on the balance of probabilities, applied flexibly according to the seriousness of the allegation in accordance with the principles set out by the courts in applicable caselaw, or who is convicted of an offence relating to abuse and neglect in care, should be permanently removed from ministry. Members of the Church should be notified of the persons permanent removal from ministry. Faith-based entities should also take all necessary steps to effectively prohibit the person from in any way holding himself or herself out as being a person with religious authority.

Tūtohi | Recommendation 108

Any person in religious ministry who is convicted of an offence relating to abuse and neglect in care should:

a. in the case of Catholic priests and religious, be dismissed from the priesthood and/or dispensed from his or her vows as a religious
b. in the case of Anglican clergy, be deposed from holy orders
c. in the case of an ordained person in any other religious denomination that has a concept of ordination, holy orders and / or vows, be dismissed, deposed, or otherwise effectively have their religious status removed.

Tūtohi | Recommendation 109

Where a faith-based entity becomes aware that any person attending any of its religious services or activities is the subject of a substantiated complaint of abuse and neglect in care, or has been convicted of an offence relating to abuse and neglect in care, the faith-based entity should:

a. assess the level of risk posed to children, young people, and adults in care by that perpetrator’s ongoing involvement in the religious community
b. take appropriate steps to manage that risk.

Tūtohi | Recommendation 110

Each faith-based entity should consider establishing a national register which records limited but sufficient information to assist affiliated institutions to identify and respond to any risks to children, young people and adults in care that may be posed by people in religious or pastoral ministry.

Recommendations 111–116: Communities are empowered to minimise the need for out of whānau care
Ngā tūtohi 111–116: He whakaāhei i ngā whānau ki te āta aukati i ngā mahi kaitiaki i waho i te whānau

Tūtohi | Recommendation 111

The government should invest in a nationwide social and educational campaign to address attitudes and beliefs that contribute to harmful and discriminatory experiences in care and promote positive understanding and awareness of the diversity of experiences in Aotearoa New Zealand. This campaign should focus on addressing:

a. negative attitudes towards children and young people
b. attitudes reflective of discrimination based on race, gender and sexuality
c. attitudes reflective of eugenics, ableism and disablism.

Tūtohi | Recommendation 112

The government should invest further in nationwide social and educational campaigns to:

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

Tūtohi | Recommendation 113

The government and faith-based entities should disseminate and publicise the findings and recommendations of this Inquiry in the widest and most transparent manner possible.

Tūtohi | Recommendation 114

The government should:

a. accelerate and prioritise current policy and legislative work to enable children, young people and adults in care and their whānau to more effectively participate in decisions that affect them, and to bring the strength of communities into decision-making
b. review legislation, policy, investments, operational practice and guidelines related to the care of children, young people, and adults in care to identify opportunities to enable children, young people and adults in care and their whānau to more effectively participate in decisions that affect them, and to bring the strength of communities into decision-making.

Tūtohi | Recommendation 115

The government should prioritise and invest in work to support contemporary approaches to the delivery of care and support, including devolution, social investment, whānau-centered and community-led approaches, such as Enabling Good Lives and Whānau Ora, and avoid the State-led models that contributed to historical abuse and neglect in care.

Tūtohi | Recommendation 116

Commissioners Erueti and Gibson consider the government should:

a. develop, plan for, and establish an independent entity, as soon as possible, responsible for:

i. commissioning care and protection, youth justice, community mental health, disability and preventative services and supports from self-identified local (or in some cases, national) community groups and organisations (including hapū, iwi, urban Māori authorities, NGOs, Pacific, disability, mental distress communities, faith-based entities, and other collectives) across Aotearoa New Zealand
ii. monitoring and evaluation of the delivery of care and protection, youth justice, community mental health, disability and preventative services and supports by local community groups and organisations to ensure that they are meeting the needs of individuals and whānau in their communities
iii. investing in local community groups and organisations to build their capacity and capability to design and deliver these supports and services to meet the needs of their communities
iv. reporting to government, Parliament and the public on the delivery of care and protection, youth justice, community mental health, disability and preventative services and supports by local community groups and organisations to ensure that they are meeting the needs of individuals and whānau in their communities

b. provide sufficient and sustainable investment to the Commissioning Agency to enable it to commission care and protection, youth justice, community mental health, disability and preventative supports and services that will meet the needs of individuals and whānau nationwide

c. transfer responsibility and investment for commissioning the following services and supports to the Commissioning Agency:

i. care and protection supports and services, from Oranga Tamariki
ii. youth justice supports and services, from Oranga Tamariki
iii. community mental health supports and services, from the Ministry of Health/Health New Zealand Te Whatu Ora
iv. disability supports and services, from Whaikaha
v. preventative supports and services, from Te Puni Kōkiri/Whānau Ora commissioning entities.

Recommendation 117–120: Giving effect to te Tiriti o Waitangi and human rights
Ngā tūtohi 117–120: Te whakamana i te Tiriti o Waitangi me ngā mōtika tāngata

Tūtohi | Recommendation 117

The government 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 the development of strategy, policy, design, implementation and direct or indirect delivery of care functions, including where it has passed on its authority or care functions to any faith-based institution, or to any other individual, entity, or service provider (whether by delegation, contract, licence, or in any other way).

Tūtohi | Recommendation 118

All entities providing care directly or indirectly on behalf of the State or faith-based entities should:

a. uphold the rights of Māori in care as indigenous peoples of Aotearoa New Zealand in accordance with United Nations Declaration on the Rights of Indigenous Peoples
b. uphold the rights of Māori, Pacific Peoples, and people from other linguistically or culturally diverse backgrounds in care, in accordance with the Convention on the Elimination of All Forms of Racial Discrimination
c. uphold the rights of girls and women in care, in accordance with the Convention on the Elimination of All Forms of Discrimination against Women
d. uphold the rights of Deaf, disabled people and people who experience mental distress in care, in accordance with the Convention on the Rights of Persons with Disabilities and the Enabling Good Lives principles, including:

i. recognition that Deaf, disabled people and people who experience mental distress, in care have:

- the same rights as others in care to make decisions that affect their lives, including adults having decision-making supports as appropriate
- the right to communication assistance in making and participating in decisions that affect them, communicating their will and preferences, and developing their decision-making ability
- the right to access and use advocacy services in making and participating in decisions and communicating their will and preferences

ii. recognition that tāngata Turi, tāngata whaikaha and tāngata whaiora Māori and Pacific Peoples who are Deaf, disabled or experience mental distress may experience barriers to accessing supports and services due to cultural, language and other differences, and that these barriers need to be addressed.

e. uphold the rights of the child in care, including:

i. acting with the best interests of the child as a primary consideration, consistent with the United Nations Convention on the Rights of the Child
ii. recognising the right of whānau, hapū, iwi and Māori to retain shared responsibility for the wellbeing of tamariki and rangatahi Māori, consistent with the United Nations Declaration on the Rights of Indigenous Peoples.

Tūtohi | Recommendation 119

The government should review Aotearoa New Zealand’s human rights framework to ensure it adequately addresses abuse and neglect in care, including:

a. a stand-alone right to security of the person in the New Zealand Bill of Rights Act 1990
b. ensuring statutory protection in a Disability Rights Act of the rights of disabled people to be free from abuse and neglect in care and the relevant rights in the Convention on the Rights of Persons with Disabilities
c. providing statutory protection of the rights of Māori to be free from abuse and neglect in care and the relevant rights in the United Nations Declaration on the Rights of Indigenous Peoples
d. making any necessary amendment to the Human Rights Act 1993 to address abuse and neglect in care
e. the provision of effective implementation of the relevant rights, including positive duties.

Tūtohi | Recommendation 120

The government should establish performance indicators for all entities providing care directly or indirectly on behalf of the State or faith-based entities based on Aotearoa New Zealand’s domestic and international obligations.

Recommendations 121–122: Targeted abuse and neglect prevention programmes
Ngā tūtohi 121–122: He aronga tūturu ki ngā kaupapa ārai mahi tūkino

Tūtohi | Recommendation 121

The government should support and adequately invest in:

a. programmes for children, young people and adults who are in care or are at risk of being placed in care that are delivered through community organisations, and preschool, primary, and secondary schools including kura kaupapa, private, charter and State integrated schools, that aim to increase knowledge about abuse and neglect and build their skills and tools to help them to protect themselves (both in person and online safety), including a focus on:

i. recognising grooming and other inappropriate behaviour
ii. understanding what constitutes abuse and neglect
iii. recognising the signs of abuse and neglect
iv. understanding their rights and how they should be treated
v. understanding respectful and appropriate behaviour and relationships
vi. what to do and where to get help if you have concerns.

b. programmes to help support parents, whānau and caregivers delivered through day care, preschool, school, sport and recreational settings, and other institutional and community settings to increase knowledge of abuse and neglect and its impacts and build skills to help reduce the risks of abuse and neglect.

Tūtohi | Recommendation 122

The government should support and adequately invest in:

a. abuse and neglect prevention programmes, including for those who may be at risk of perpetrating abuse and neglect
b. access to specialist support, including rehabilitation programmes, for children, young people and adults who exhibit harmful or abusive behaviours or are at risk of abusing others, including concerning or harmful sexual behaviours
c. online information and a helpline to provide support for those concerned about:

i. an adult they know may be at risk of perpetrating abuse and / or neglect
ii. a child, young person or adult in care they know may be at risk of abuse and / or neglect
iii. a child, young person or adult in care they know may be displaying potential abusive behaviours.

Recommendations 123–124: Establishing a Care System Office to lead implementation
Ngā tūtohi 123–124: Te whakatū Tari Pūnaha Āhuru Mōwai motuhake hei arataki i te kaupapa

Tūtohi | Recommendation 123

The government should establish a Care System Office later to become the Ministry for the 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 | Recommendation 124

The new 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 new Act
e. providing whole of system advice to government on the care sector, settings and system.

Recommendation 125: Taking any and all actions needed to give effect to these recommendations
Tūtohi 125: Me mahi ngā mea katoa e rite e whai take ai ēnei whakatau

Tūtohi | 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.

Recommendation 126–127: Implementation of all recommendations to give effect to te Tiriti o Waitangi and UNDRIP, and be co-designed with communities

Ngā tutohi 126–127: 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

Tūtohi | 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 the 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.

Tūtohi | 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, 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.

Recommendation 128: Public awareness and training to prevent abuse and neglect, and address prejudice and discrimination
Tūtohi 128: Whakatū kaupapa hautū aronga ako me te whakamātau i te iwi whānui kia mōhio me te ārai i ngā mahi tūkino, whakahāwea, whakaiti tangata

Tūtohi | 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, and 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. 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.

Recommendation 129: New entity appointments to reflect diversity, survivor experience and give effect to te Tiriti o Waitangi
Tūtohi 129: Ko ngā kaimahi o tēnei tari me whai pukenga whānui, wheako purapura ora, e hua ai ngā pānga ki te Tiriti o Waitangi

Tūtohi | 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 Mara 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.

Recommendations 130–138: Transparency and public accountability for implementing the Inquiry's recommendations
Ngā tūtohi 130–138: Kia mārama, kia pono ki ngā whāinga tūmatanui e hua ai ngā tūtohinga o tēnei Pakirehua

Tūtohi | Recommendation 130

The government and faith-based institutions should publish their responses to this report and the Inquiry’s interim reports on 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 | 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.

Tūtohi | Recommendation 132

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

Tūtohi | 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 | Recommendation 134

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

Tūtohi | Recommendation 135

The government and faith-based entities should implement the Inquiry’s recommendations within 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.

Tūtohi | 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 | 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 | 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.

Footnotes

[1] Z v Dental Complaints Assessment Committee [2008] NZSC 55.