Summary of key findings Whakarāpopoto o ngā whakakitenga

70. The key findings of the Inquiry are listed below. These key findings should be read alongside the more specific findings contained in the case studies, the Inquiry's previous interim reports, and in the text of this final report.

Wāhanga 3: Ngā tipua whakawai
Part 3: Circumstances

71. Clause 31(d) of the Terms of Reference requires the Inquiry to make findings on the circumstances that led to individuals being taken or placed into care during the Inquiry period.

72. Between 1950 and 1999 State and faith-based institutions had hundreds of thousands of people in their care. The wide definition of care in the Inquiry's Terms of Reference means there were many different pathways into care, from State-enforced removals, court orders, or a lack of alternative options through to voluntary relationships such as private schooling and pastoral care.

73. The Inquiry finds:

People were more likely to be placed in State and faith-based residential and institutional (direct or indirect) care if they had experienced poverty, family crisis or violence, parental abuse and neglect, or were Deaf, disabled or mentally distressed particularly if there was a lack of support for the household from others.
The effects of colonisation, urbanisation, the break-down of social structures, and racism saw Māori more likely to be placed in State care.
In some situations, a care placement was necessary for the health and safety of the person concerned. Decision-makers believed that out-of-whānau care would lead to better life outcomes. Those beliefs were usually genuinely held but often without foundation.
Parents were often convinced, sometimes through religious affiliation, that care placements outside the home or mainstream education would provide superior environments or opportunities for their children.
In the State care system, decision-makers included social workers, police, judges, health professionals and needs assessors who generally had limited involvement in, connection with, or understanding of the most affected communities (including Māori, Pacific Peoples, Deaf or disabled communities, those with mental distress).
The State often used formal powers as well as compulsory and institutional care options in a discriminatory way. Formal legal orders were more often used against Māori rather than supporting in-home, whānau, hapū, iwi or community care.
Many survivors experienced multiple placements, between different settings, often due to perceived delinquency or a lack of support within care residences or institutions.
Children, young people and adults in care did not always understand why they were being moved or where they were going next. They were often scared, confused, and missed their whānau.
Decision-making was often influenced by ableist and disablist attitudes which led to the segregation and social exclusion of Deaf, disabled people and people experiencing mental distress.
Tamariki and rangatahi Māori were the majority in social welfare care settings and were over-represented in all other institutional and compulsory care settings.
Tamariki and rangatahi Māori were more likely to be sent to harsher institutions such as borstals and social welfare residences and institutions.
The State often failed to assess, or inadequately assessed, children, young people, and adults in care for trauma and support needs when deciding on care options.
The State almost always failed to consider or recognise an ao Māori (Māori world) view, tikanga, te reo and mātauranga Māori when removing or placing tamariki, rangatahi and pakeke Māori in all care settings. These failures were both in the method of removal and the appropriateness of placements.
The State did not typically consider placements with whānau, hapū or iwi for tamariki, rangatahi and pakeke Māori. Nor did the State actively support sustained connections to whānau, hapū, iwi or community for those in care.
Between the 1950s and 1980s, tamariki, rangatahi and pakeke Māori experienced heightened State surveillance and targeting by NZ Police and other State agencies, which contributed to a disproportionate number of tamariki, rangatahi and pakeke Māori entering State care. Wāhine Māori experienced heightened State surveillance for running away, staying out or behaving in ways perceived as promiscuous.
Deaf, disabled and mentally distressed children, young people or adults were placed in most care settings. Many settings were established only for disabled and mentally distressed people. There was special, segregated residential schools for Deaf children and young people.
There was an over-use of institutional care for Deaf, disabled and mentally distressed children, young people, and adults.
Deaf, disabled and mentally distressed children, young people and adults were often denied or restricted from involvement in decisions about their own lives.
For many Deaf, disabled and mentally distressed people, formal State care was the only option the State provided, often for their entire life. The State failed to provide any alternatives.
The State generally failed to consider or recognise Pacific world views, cultural values (fa'asamoa, anga, fakatonga), Pacific languages and Pacific knowledge when removing or placing children (fanau), young people (tagata talavou) or adults (tagata matua) in all care settings. These failures were both in the method of removal and the appropriateness of placements. Wider kainga (family) or Pacific communities were not generally considered as an alternative option for care.
Between the 1950s and 1980s, Pacific Peoples experienced heightened State surveillance and targeting by NZ Police and other State agencies, contributing to a disproportionate number of Pacific Peoples entering State care. Challenges with immigration, including language barriers, poverty and societal attitudes also contributed to Pacific Peoples entering care settings.
Between the 1950s and 1970s, many unmarried pregnant girls and women were placed in faith-based homes. These homes often facilitated the subsequent adoptions of babies. These placements and adoptions were usually the result of family, religious and societal attitudes including racism.
Adoption practices facilitated by the State or faith-based institutions for Māori were discriminatory and ignored whāngai Māori practices. From 1950 to the mid-1980s, adoption practices legally severed tamariki and rangatahi Māori from their whakapapa and identity.

Wāhanga 4: Māngai nuitia te kupu pono
Part 4: Nature and Extent

74. Clause 31(a) of the Terms of Reference requires the Inquiry to make findings on the nature and extent of abuse and neglect that occurred during the Inquiry period.

75. The Inquiry finds:

The best available estimates indicate that up to 200,000 people were abused in care between 1950 and 1999. Precise figures are impossible due to data inadequacies and poor records kept by the State and faith-based institutions, the passage of time, barriers to disclosure, abuse going unreported, and steps commonly taken to conceal abuse. The total number may be higher than this estimate.
Many different forms of abuse and neglect were reported to the Inquiry. These included:
1. entry into care caused trauma
2. psychological and emotional abuse and neglect
3. physical abuse and neglect
4. sexual abuse racial abuse and cultural neglect
5. spiritual and religious abuse and neglect
6. medical abuse and neglect
7. solitary confinement
8. financial abuse and forced labour
9. educational neglect.
Sexual, physical and emotional abuse were the most common forms of abuse in care. Neglect was pervasive across all care settings and varied according to the setting.
People experienced racism in all care settings.
Policies and practices that would now be understood as ableist and disablist were common across all settings.
In some residential and institutional care settings, some children, young people and adults in care experienced the over-use of seclusion, over-medicalisation, lobotomies, sterilisation, invasive genital examinations and experimental psychiatric treatments without informed consent.
Abuse and neglect were pervasive in social welfare, Deaf, disability, and mental health residences and institutions.
State care, particularly in social welfare residences and institutions, often used punishment and control rather than care.
Tamariki, rangatahi and pakeke Māori placed in Pākehā value-based institutions often experienced severe abuse and neglect including patu (hitting/striking), whakamamae (inflicting pain) and whakarere (neglect). This was a transgression against whakapapa, personal tapu, mana, mauri and wairua.
Some survivors endured extensive and extreme abuse and neglect. At times, surviving severe physical pain and/or mental suffering.
From the over 2,300 survivors who spoke to the Inquiry:
1. many survivors experienced multiple forms of abuse and neglect, for example, 82 percent of survivors who spoke to us about sexual abuse also reported physical abuse
2. abuse and neglect were particularly prevalent in social welfare settings, faith settings (particularly Catholic, Anglican, and Gloriavale) and disability and mental health settings
3. residential and institutional care in social welfare, education and health and disability care settings typically had highly regimented systems. These types of institutions had high levels of physical abuse. The highest levels of physical abuse were reported at Wesleydale Boys' Home and Ōwairaka Boys' Home, both in Tāmaki Makaurau Auckland
4. tamariki, rangatahi and pakeke Māori were more likely to experience neglect compared to non-Māori children, young people, and adults in care
5. children aged 10-14 endured high levels of sexual and physical abuse
6. Māori and Pacific survivors endured higher levels of physical abuse than other ethnicities
7. disabled survivors suffered higher levels of all forms of abuse than non-disabled survivors
8. Deaf and disabled survivors were more likely to report physical, emotional, and sexual abuse than other forms of abuse
9. a higher proportion of survivors in faith settings than in State care were sexually abused. The highest reported levels of sexual abuse were at Dilworth School in Tāmaki Makaurau Auckland (Anglican), Marylands School in Ōtautahi Christchurch (Catholic) and at Catholic institutions in general
10. children and young people in foster care experienced the highest levels of sexual abuse among social welfare care settings
11. the decade with the highest rates of abuse and neglect was the 1970s, followed by the 1960s and then the 1980s
12. some survivors reported the misuse of solitary confinement or seclusion
13. male survivors reported higher levels of abuse than females, including sexual abuse. Males experienced higher levels of physical abuse than other forms of abuse
14. female survivors were more likely to experience emotional and sexual abuse, compared to other forms of abuse. Females experienced higher levels of neglect compared to males.
At the Lake Alice Child and Adolescent Unit, as set out in the Inquiry's interim report Beautiful Children, abuse included:
1. electric shocks and injections of paraldehyde as punishment, administered to various parts of the body including the head, torso, legs and genitals
2. the misuse of solitary confinement
3. patients exposed to unreasonable medical risks.
  
  Go to the Inquiry's interim report Beautiful Children: Inquiry into the Lake Alice Child and Adolescent Unit
At Marylands School and Hebron Trust, as detailed in the Inquiry's interim report Stolen Lives, Marked Souls:
1. abuse and neglect was extensive and extreme
2. sexual abuse was pervasive
3. physical, emotional, and psychological abuse led to some survivors living in perpetual fear
4. evidence suggests the abuse was used as punishment as well as to intimidate
5. there was pervasive neglect including neglect of basic needs as well as cultural, medical, and emotional needs
6. children and young people suffered mental and physical pain
7. cultural and religious abuse was extensive
8. survivors experienced racism.
  
  Go to the Inquiry's interim report Stolen Lives, Marked Souls
At Te Whakapakiri Youth Programme on Aotea Great Barrier Island, as detailed in the Inquiry's case study:
1. abuse and neglect were pervasive and extreme
2. young people experienced severe physical violence
3. young people were sent alone to an isolated island for days at a time as punishment
4. there is evidence of young people being threatened with death through mock executions.
  
  Go to the Inquiry's case study Boot Camp: Te Whakapakari Youth Programme
At the Kimberley Centre near Taitoko Levin, as detailed in the Inquiry's case study:
1. disabled children, young people and adults suffered severe and chronic abuse and neglect
2. physical and sexual abuse of disabled children, young people and adults was pervasive and severe
3. physical abuse was common and normalised. This was reflected by the 'Kimberley cringe' where survivors would cower and protect their head if they were approached quickly
4. people experienced extreme neglect of their physical, emotional, psychological, educational, medical, and dental needs
5. nutritional practices were poor with some disabled children, young people and adults not fed for long periods or fed with feeding tubes that were later assessed as not medically required
6. the physical environment was neglectful with few activities and little to occupy disabled children, young people, and adults in care, who spent 80 percent of their time engaged in no purposeful activity.
  
  Go to the Inquiry's case study Out of sight, out of mind: Kimberley Centre
At Kelston School for the Deaf in Tāmaki Makaurau Auckland, and Van Asch College in Ōtautahi Christchurch, as detailed in the Inquiry's case study:
1. Deaf students experienced regular sexual, physical, verbal and psychological abuse
2. physical violence was normalised and pervasive
3. all Deaf children and young people experienced linguistic abuse, and neglect and language suppression
4. Deaf children and young people were punished for using Sign Language and their Deaf culture and identity were not supported.
  
  Go to the Inquiry's case study Our hands were tied: Van Asch College and Kelson School for the Deaf
At Hokio Beach School in Taitoko Levin and Kohitere Boys' Training Centre in Taitoko Levin, as detailed in the Inquiry's case study:
1. there were cultures of normalised and pervasive violence, with many experiencing severe corporal punishment, sometimes inflicted with weapons and to the genitals
2. staff condoned and encouraged peer-on-peer violence through a king-pin system including violent 'stomping' initiations of new boys
3. sexual abuse was pervasive
4. solitary confinement was misused
5. racism and cultural abuse was normalised
6. staff punished boys with extreme physical training and inhumane tasks, often physically assaulting them at the same time.
  
  Go to the Inquiry's case study Cauldron of Violence: Hokio Beach School and Kohitere Boys' Training Centre

Wāhanga 5: I mahue kau noa i te tika
Part 5: The Impacts of Abuse in Care

76. Clause 31(c) of the Terms of Reference requires the Inquiry to make findings on the impact of the abuse and neglect on individuals and their families, whānau, kainga (family), hapū, iwi, and communities during the Inquiry.

77. The Inquiry finds:

Many survivors who were abused or neglected in care have gone on to lead fulfilling lives, and some have worked courageously to improve the future for children, young people, and adults in care in Aotearoa.
Some people who were abused or neglected in care took their own lives or died because of their experiences in care.
Evidence of unmarked graves for patients who died at some psychiatric hospitals across Aotearoa New Zealand, particularly at Porirua, Tokanui and Sunnyside Hospitals.
Most survivors suffered harm and have not been able to live their lives to their full potential. The impacts have been life-long or temporary. These were and are co-occurring, where one type of impact of abuse or neglect will intersect with other impacts. Impacts have included:
1. difficulty with establishing intimate relationships
2. difficulty with maintaining family relationships
3. devastating effects on their health and wellbeing
4. damaged mental health and emotional wellbeing
5. lack of education opportunities impacting on ability to participate in society
6. reduced opportunities for gaining and maintaining employment opportunities
7. increased financial insecurity
8. experiencing periods of homelessness
9. reduced trust in authority
10. for some, pathways into addiction
11. for some, pathways into sex work
12. for some, pathways into criminality and prison
13. for some, pathways into gang membership
14. for some, entrapped in institutional care
15. struggles with sexuality and gender identity
For Māori survivors in addition to the impacts outlined above, they experienced:
1. disconnection from whakapapa and te ao Māori
2. loss of identity as Māori, te reo, tikanga and matauranga Māori
3. loss of confidence resulting from this loss of identity.
Survivors struggled to understand their identity.
Many survivors were already at risk of poor life outcomes before they went into care due to poverty, trauma, and the need for additional support from others. Instead of receiving support and protection in care, these survivors experienced abuse and neglect.
During the Inquiry period, harm was pervasive in social welfare institutions. over 30 percent of children and young people went on to serve prison sentences later in life. Tamariki and rangatahi Māori were significantly over-represented in these numbers.
Māori survivors, including tangata Turi Māori, tangata kāpō Māori, whānau hauā Māori, tāngata whaikaha Māori and tangata whaiaora Māori often experienced disconnection and isolation from their whānau, hapū, iwi and whenua, and their ability to access and participate in te ao Māori. This disconnected them from their tūrangawaewae, causing many to feel a deep sense of whakamā and isolation. This disconnection and the ongoing impacts of colonisation and urbanisation compounded the impacts of the abuse and neglect they suffered. These impacts were felt intergenerationally, particular by survivors' children and grandchildren, and collectively by hapū and iwi.
The intergenerational impact of abuse and neglect has been experienced by their children, grandchildren, whānau and future generations. The impacts have also affected their support networks, hapū, iwi and communities.
Some whānau, support networks, hapū, iwi or communities of survivors experienced guilt and regret for the harm experienced by their loved-ones while they were in care.
Whānau, hapū and iwi were deprived of exercising tino rangatiratanga over kāinga (home) by caring for and nurturing the next generation.
For tamariki, rangatahi and pakeke Māori, the impacts of abuse and neglect in care caused a disruption to the collective ability of Māori to live as Māori and to participate and contribute to Māori social, cultural, and political life within whānau, hapū and iwi. There has been a loss of members to transfer cultural practices, tikanga, te reo and mātauranga Māori which also has inter-generational impacts, a loss of potential leadership to sit on taumata or on the paepae and is a transgression of whakapapa.
Often when children, young people and adults in care returned home reintegration was difficult, or never achieved. Some people were never able to return or have any ongoing connection with their whānau, support networks, hapū, iwi or communities.
Deaf, disabled, and mentally distressed survivors, including tangata Turi Māori, tangata kāpō Māori, whānau hauā Māori, tāngata whaikaha Māori and tangata whaiaora Māori experienced ongoing daily discrimination which further impacted their lives, led to invisibility and sometimes limited or restricted their ability to leave care.
Pacific survivors often experienced a loss of connection to their kainga (family), culture, language, and cultural identity. This breached the vā, resulting in trauma that has been carried from generation to generation.
The lack of acknowledgement or apology from those in power creates further trauma for survivors. Where acknowledgements have been made, they were often too little and too late.
Abuse and neglect, and the ongoing associated intergenerational harm and trauma, have contributed to social inequities.
The average lifetime cost to the survivor of the loss of enjoyment of things that New Zealanders think are normal day-to-day activities was estimated in 2019 to be approximately $673,000, which is almost 80 percent of the estimated lifetime costs of abuse per survivor of $857,000.
Based on the estimated number of people abused and neglected in care between 1950 and 2019, the total cost is estimated to be between $97.5 billion and $219 billion. Of this the smallest proportion estimated to be approximately $47.1 billion is borne by the taxpayers of New Zealand. The largest cost, estimated to be approximately $172 billion, is borne by survivors.

Wāhanga 7: Ngā haukino o te wā
Part 7: Factors

Ngā takahi paerewa
Breaches of relevant standards

78. Clause 33 of the Terms of Reference allows the Inquiry to make findings that relevant standards have been breached. In summary, the Inquiry finds that, during the Inquiry period:

Ngā takahi i te Tiriti o Waitangi | Breaches of te Tiriti o Waitangi

Te Tiriti o Waitangi guaranteed rights to Māori throughout the Inquiry period that should have been protected and upheld.
The Crown deprived whānau, hāpu and iwi of exercising tino rangatiratanga over their kāinga (home), to care and nurture the next generation and regulate the lives of their people, and that this breached the principle of active protection in te Tiriti o Waitangi.
The Crown’s failure to address the on-going effects of colonisation that contributed to tamariki, rangatahi and pakeke Māori being placed in care and breached the guarantee of tino rangatiratanga and the principle of active protection in te Tiriti o Waitangi.
The Crown failed to protect Māori survivors from losing their whakapapa and connection to whānau, hapū and iwi. This breached the principles of tino rangatiratanga, kāwanatanga (just, fair, and equitable policies and laws), partnership, active protection, and options in te Tiriti o Waitangi. 
The Crown excluded Māori from decision-making, developing and implementing policies that directly impacted the care of tamariki, rangatahi, and pakeke Māori. This breached the guarantee of tino rangatiratanga and the principles of partnership and active protection in te Tiriti o Waitangi.
The Crown’s general exclusion of Māori models of care breached the principles of partnership, active protection, equity, and options in te Tiriti o Waitangi.
The Crown stripped Māori of their cultural identity through structural racism. This breached the guarantee of tino rangatiratanga and the principles of kāwanatanga, partnership, active protection, and equity in te Tiriti o Waitangi.
The Crown denied the use of te reo Māori through the introduction of policies and practices in care settings and this breached the principle of active protection in te Tiriti o Waitangi.
The Crown failed to protect Māori from many forms of abuse and neglect once in care. This breached the principle of active protection in te Tiriti o Waitangi.
The Crown failed to collect accurate records of the abuse and neglect experienced by tamariki, rangatahi and pakeke in care. This breached principle of good governance in te Tiriti o Waitangi.
The Crown failed to ensure that tamariki, rangatahi and pakeke in care did not experience racism. This breached the principles of equity and equal treatment in te Tiriti o Waitangi.
Through failing to appropriately address trauma, caused by abuse and neglect in care the Crown failed to prevent inter-generational impacts on Māori, whānau, hapū, and iwi. This breached the principle of active protection in te Tiriti o Waitangi.
The Crown failed to provide appropriate redress for those who suffered abuse and neglect.

Ngā takahi i ngā paerewa atawhai | Breaches of standards of care

1. People in care had rights to standards of care that prevented abuse (ill-treatment) and neglect during the Inquiry period. However:
  1. In some settings, particularly disability and mental health, education and faith, the government failed to set adequate or overarching standards of care
  2. In Deaf, disability and mental health settings, institutions breached the standards they set. Specifically, survivors' rights to dignity and respect, adequate protection from abuse, neglect and exploitation and proper daily care were consistently breached.
  3. In social welfare settings, staff, social workers, and foster parents breached the standards of care set out in the Department of Education Field Officers Manual and its later versions (including the Social Workers Manual)
  4. In transitional and law enforcement settings, NZ Police breached the standards set in their General Instructions. Specifically by interrogating young people with violence and without the presence of an adult and by holding them in police cells.
2. There were regular and routinely breaches of standards of care with significant impacts for many children, young people and adults in care whose standards were breached.
3. In many institutions, residences, and foster homes, standards were breached every day, due to a lack of resourcing, poor training and confusion about statutory powers and the role of staff or foster parents.
4. Breaches of standards varied in severity. Many were extremely serious. Some breaches of standards were in themselves abuse, while others allowed abuse and neglect to occur.
5. Breaches of standards of care included:
  1. neglect and abuse (ill-treatment), including sexual abuse, that was severe, extensive, extreme or pervasive in some institutions
  2. wrongful use of seclusion, solitary confinement and secure care
  3. frequent use of corporal punishment, which at times was extreme and perverse punishment involving weapons and humiliation.
  4. frequent breaches of health care standards, at times unlawfully, including:
    - lobotomies, sterilisation, forced adoptions, invasive genital examinations, over medicating, and experimental psychiatric treatments without informed consent 
    - in psychiatric facilities, electric shocks and injections of paraldehyde as punishment, and exposing patients to unreasonable medical risks
    - medical neglect and abuse
    - medicating people in care for long periods without review
    - not providing access to doctors or health specialists for extended periods
    - failing to provide a medical certificate on admission to a residence or institution.
  5. the failure of some social workers to visit State wards in care, a key intervention and rescue point for people experiencing abuse or neglect
  6. serious breaches of transitional and law enforcement standards, such as:
    - people in care questioned without the presence of a parent, guardian or lawyer
    - interrogations using physical violence
    - coercion to confess to crimes, even when innocent
    - stays in police cells, overnight, sometimes up to weeks.
Ngā take i hua ai te mahi tūkino i ngā pūnaha taurima
Factors which caused or contributed to abuse and neglect in care

79. Clause 31(b) of the Terms of Reference requires the Inquiry to make findings on the factors, including systemic factors, which caused or contributed to abuse and neglect.
80. Clause 10.2 of the Terms of Reference refers to factors that include, but are not limited to, the standards that applied in care settings, the vetting, recruitment, training, development and supervisions of staff and carers, the processes available to people in care for raising concerns or complaints, the processes in place to respond to those complaints and how effective they were.

81. In summary, during the Inquiry period the Inquiry finds:

Te hunga i te pū o ngā mahi tūkino| The people at the centre of abuse and neglect
1. 1. 1. Children, young people, and adults in care were diverse, with different care and support needs.
    2. Children, young people, and adults in care needed support, protection, and safeguarding when in care.
    3. Strong protective factors significantly reduce the risk of abuse and neglect and the likelihood of entry into care.
    4. Strong protective factors include connection to whānau, strong self-esteem, supportive trustworthy adults and friends and an understanding of inappropriate behaviour and what to do in difficult situations.
    5. The rights guaranteed in te Tiriti o Waitangi are a layer of protection for whānau, hapū, and iwi and their tamariki, rangatahi and pakeke. These rights also reinforce protective factors.
    6. Human rights are a layer of protection for children, young people, and adults in care, and their families, whānau, and individual mothers and fathers. Human rights also reinforce protective factors.
    7. Many people entering care had weakened protective factors, contributing to the risk they would experience abuse and neglect.
    8. Many tamariki, rangatahi and pakeke Māori entered care with few protective factors.
    9. Many of the circumstances that made it more likely a person would enter care often became the circumstances for why they were more susceptible to abuse and neglect in care. Those circumstances included:
      1. being raised in poverty and experiencing deprivation 
      2. being disabled with unmet needs 
      3. being Māori and racially targeted 
      4. being Pacific and racially targeted 
      5. being Deaf with unmet needs  
      6. experiencing mental distress with unmet needs  
      7. being Takatāpui, Rainbow, MVPFAFF+, gender diverse or transgender and targeted  
      8. experiencing significant or multiple adverse childhood events, including: 
        
        experiencing violence, abuse, or neglect in private homes or in other care settings   
        
        witnessing violence in private homes or in the community or in other care settings  
        
        having a family member or a peer in a care setting pass away, or attempt or die by suicide  
        
        aspects of their environment that undermined their sense of safety, stability, and bonding, such as
        
        growing up in a private home or in other care settings:  
        
        with parents, caregivers, or peers experiencing substance use problems  
        
        with parents, caregivers, or peers experiencing mental distress  
        
        where there is instability due to parental separation or household members being incarcerated  
        
        living in an under-resourced private home or becoming homeless  
        
        experiencing unsupported and weakened family and cultural structures  
        
        being in families and communities that were unsupported because their needs had not been adequately assessed or met
      9. having a deferential attitude to people in positions of authority, including faith leaders and medical professionals
      10. other circumstances such as age or gender, and 
      11. experiencing or being any combination of the above.
    10. Abusers were able to misuse their positions of power and control over people in their care to inflict at times extreme and severe abuse and neglect.
    11. Abusers were often predatory.
    12. Abusers exploited the powerlessness and vulnerability of those they were abusing or neglecting.
    13. Abusers often acted with impunity.
    14. Some survivors were abused by peers. The risk of peer-on-peer abuse increased when the abuser knew that staff or carers would not hold them to account.
    15. Most abusers took steps to conceal their actions. They ensured that survivors’ complaints about abuse and neglect were ignored or suppressed.
    16. Many abusers avoided accountability, allowing them to abuse for extended periods and across multiple residences and institutions.
    17. Many bystanders (staff, volunteers and carers) failed to stop or report abuse and neglect that they observed or suspected was occurring.

Take hinonga | Institutional factors

The following institutional factors contributed to abuse and neglect in care:
1. inadequate, inconsistent and inaccessible standards (including the lack of commitment to human rights and te Tiriti o Waitangi) of care which were routinely breached with little consequence or accountability
2. individual care needs were not routinely or accurately identified, recorded and met
3. poor employment policies and poor senior leadership and management practices, including:
  - - - poor or inadequate vetting policies, exacerbated by a lack of access to NZ Police vetting for most settings
      - senior leaders and managers sometimes skipping vetting requirements
      - senior leaders and managers sometimes knowingly employing abusers with criminal convictions for sexual abuse
      - a lack of staff and carer diversity
      - under investment in staff and carers
      - recruitment of people with service or military backgrounds that contributed to punitive, command and control models of care in some institutions
      - poor or inadequate training and development specific to care roles, and on how to recognise the signs of abuse and neglect in care
4. widely variable, absent, or inaccessible complaints processes that were poorly implemented, including:
  - - - barriers faced by people in care to raise concerns or complaints, including a lack of access to whānau, communities, and advocates
      - consistent failures to believe people in care when they reported abuse or neglect, underpinned by societal attitudes like racism, ableism and disablism
      - concerns or complaints being treated as an employment issue or as a sin to be forgiven, rather than (in many cases) criminal behaviour
      - senior leaders or managers prioritising institutional reputations over the safety of people in care
      - senior leaders or managers priorisiting abusers’ reputations and future careers over the safety of people in care, including shifting the abuser to other residences or institutions and using confidential settlements
      - consistent failures to report complaints of abuse and neglect to NZ Police
5. ineffective, ad hoc and insufficient oversight and monitoring, which did little to prevent or respond to known abuse and neglect
6. consistent accountability failures, that allowed abuse and neglect to continue and gave many abusers a sense of impunity.
The State did not take the steps it should have when it saw signs its care system was failing people in care. Those steps should have included:
1. legislation specific to care settings to give effect to the guarantees made to Māori in te Tiriti o Waitangi, particularly tino rangatiratanga
2. legislation specific to care settings to respect, protect and fulfill the human rights of people in care
3. a suite of concrete supports or special measures that prioritised the reduction of inequities for families, whānau and communities, supported them to provide care and support at home, and minimised entry into care
4. steps to minimise and ultimately end institutionalised environments and practices
5. a national framework for safety in care, designed in partnership with Māori and co-designed with people in care, their families, whānau and communities, set out in legislation and made up of:
  - - a single, overarching national strategy for safety in care that applied to all care settings, seeing them as part of one care system inclusive of faith-based care settings
    - a set of easily accessible standards of care that applied to everyone in care, that could be tailored to their needs and culture, regardless of who they were and where they were
    - the core requirements of transparent, accessible and responsive complaints processes, including access to advocates
    - blanket safety checking requirements that applied to all staff and carers, regardless of their status and role
    - consistent mandatory reporting requirements for staff and carers
    - consistent accountability for abuse and neglect in care, with swift and effective penalties for non-compliance
6. best practice training and development standards for staff and carers, and
7. independent, strategic, well-funded independent oversight and monitoring that looked across all care settings and consistently reported abuse and neglect to NZ Police.

Take ā-whakapono ake i hua ai te mahi tūkino i ngā pūnaha taurima
Faith-specific factors that caused or contributed to abuse and neglect in care

The following faith-specific factors contributed to abuse and neglect in care:
1. the authority and impunity of faith-based institutions created opportunities for abuse and neglect to occur and continue
2. discriminatory attitudes, policies and practices that contributed to abuse and neglect
3. harmful use of beliefs and practices which created environments that fostered abuse and neglect.

Take ā-pūnaha | Systemic factors

The following systemic factors contributed to abuse and neglect in care:
1. people in care, whānau and communities had limited input into State decisions about care
2. the State’s attempts to deal with institutional discrimination, which impacted who went into care and who experienced abuse and neglect in care, were lack lustre
3. legislative and policy settings were discriminatory, underpinned by societal attitudes like racism, ableism and disablism, and negative stereotypes of children, young people as delinquents, and negative attitudes towards people living in poverty
4. the State generally ignored the rights of people in care:
  - - the State did not give effect to rights guaranteed in te Tiriti o Waitangi, particularly tino rangatiratanga
    - the State did not progressively respect, protect and fulfil the human rights of people in care and their whānau
5. the State lacked diversity and lived experience of care in its leadership
6. the State did not ensure people in care were safeguarded from abuse or neglect, or had effective oversight and monitoring
7. there was a lack of State accountability for abuse and neglect, particularly those with statutory responsibilities to people in care
8. the State did not ensure there was a comprehensive regulatory care framework that was enforced and properly invested in and resourced
9. the State failed to respond to signs of systemic abuse and neglect, taking no steps to understand if its system of care was failing
10. the State’s structure clouded its response to signs of system failure.
The State did not take the steps it should have when it saw signs its care system was failing people in care. Those steps should have included:
1. legislation specific to care settings to give effect to the guarantees made to Māori in te Tiriti o Waitangi, particularly tino rangatiratanga
2. legislation specific to care settings to respect, protect and fulfill the human rights of people in care
3. a suite of concrete supports or special measures that prioritised the reduction of inequities for families, whānau and communities, supported them to provide care and support at home, and minimised entry into care
4. steps to minimise and ultimately end institutionalised environments and practices
5. a national framework for safety in care, designed in partnership with Māori and co-designed with people in care, their families, whānau and communities, set out in legislation and made up of:
  1. 1. a single, overarching national strategy for safety in care that applied to all care settings, seeing them as part of one care system inclusive of faith-based care settings
    2. a set of easily accessible standards of care that applied to everyone in care, that could be tailored to their needs and culture, regardless of who they were and where they were
    3. the core requirements of transparent, accessible and responsive complaints processes, including access to advocates
    4. blanket safety checking requirements that applied to all staff and carers, regardless of their status and role
    5. consistent mandatory reporting requirements for staff and carers
    6. consistent accountability for abuse and neglect in care, with swift and effective penalties for non-compliance
6. best practice training and development standards for staff and carers, and
7. independent, strategic, well-funded independent oversight and monitoring that looked across all care settings and consistently reported abuse and neglect to NZ Police.

Take ā-iwi | Societal factors

The following societal factors contributed to abuse and neglect in care:
1. 1. Discriminatory societal attitudes like racism, ableism, disablism, sexism, homophobia, transphobia and negative stereotypes, directly contributed to survivors entering care and suffering abuse and neglect in care, with Māori and Pacific Peoples, Deaf and disabled people, people experiencing mental distress, and Takatāpui, Rainbow and MVPFAFF+ people being disproportionately affected
  2. negative views about people living in poverty and welfare dependency
  3. belief systems that upheld reverence and trust in faith-based institutions and members of faith
  4. negative views towards children and young people, as delinquents, naughty and not to be believed
  5. society condoned and tolerated institutionalisation of people for decades.

Whakatau hē | Findings of fault

82. Clause 33 of the Terms of Reference allows the Inquiry to make findings of fault. In summary, the Inquiry finds that, during the Inquiry period:

Te Kāwanatanga | The State

Ngā takinga toko i te ora | Social welfare settings

Relevant Ministers, the Superintendent of the Child Welfare Division, Department of Education and then subsequently the Director-General and Chief Executive of the Department of Social Welfare and its successors were at fault for:
1. 1. failing to address structural racism in the care system
  2. the adverse effects of structural racism on tamariki, rangatahi, and pakeke Māori in care, their whānau, hapū, and iwi, and has an ongoing detrimental impact on the relationship between Māori and the Crown
  3. failing to address structural ableism and disablism in the care system
  4. not consistently supporting whānau to prevent people from entering care
  5. insufficient emphasis on whānau-based alternatives to State care
  6. often ignoring Māori perspectives and solutions
  7. failing to fully meet the needs of all of those in care
  8. failing to ensure people in care were kept safe from harm
  9. failing to ensure caregivers in social welfare settings were properly vetted, trained, supported, and monitored
  10. inadequate policies, processes and practices to always detect and facilitate the reporting of abuse and neglect
  11. the ongoing impacts of abuse and neglect for survivors and their whānau
  12. failing to consistently believe or follow up reports of harm in social welfare settings
  13. inadequate protection and preservation of the records and case files of all people in care, which impacts survivors today.

Ngā takinga ā-Turi, whaikaha, hauora hinengaro
Deaf, disability and mental health settings

Relevant Ministers, Directors-General of Health and Directors of Mental Health were at fault for:
1. 1. the policy of institutionalisation from the 1950s to 1970s which resulted in Deaf and disabled people, and people experiencing mental distress being placed in settings where many experienced abuse and neglect. This was despite advice from the World Health Organisation that institutionalisation was opposite to best practice at the time, which was reiterated in the 1959 Burns Report by the Aotearoa New Zealand branch of the British Medical Association
  2. institutional and societal ableism in legislation, policy and systems that contributed to the abuse of Deaf and disabled people and people experiencing mental distress in health and disability institutions
  3. institutional racism in legislation, policy and systems that contributed to the abuse of Māori and Pacific Peoples in health and disability settings
  4. ableist health and disability care settings that did not always meet the needs of Deaf and disabled people and people experiencing mental distress
  5. ignoring the perspectives and solutions of disabled people and their whānau
  6. Māori, Pacific Peoples, Deaf and disabled people, and people experiencing mental distress being particularly negatively impacted, through being overrepresented in care, or their distinct needs not being met in care, including because of abuse suffered
  7. Deaf and disabled people and people experiencing mental distress not always being supported to make decisions about their own lives especially adults
  8. legislative and policy settings that did not ensure sufficient emphasis on alternatives to placing Deaf and disabled people and people experiencing mental distress into institutionalised care, like exploring family or community-based care options
  9. legislative and policy settings that did not always provide adequate support and resourcing to whānau, including disability support and resourcing
  10. failing to fully meet the needs of all of those in care
  11. not consistently and meaningfully ensuring the cultural needs of all Māori in care were met, including culturally appropriate health care options, causing disconnection from their culture, identity, language and communities, with ongoing impacts for them, and their whānau, hapū and iwi
  12. not consistently and meaningfully ensuring the cultural needs of all Pacific Peoples in care were met, including culturally appropriate health care options, causing disconnection from their culture, identity, language and communities, with ongoing impacts for them, and kainga and wider communities
  13. failing to ensure people in care were kept safe from harm when they should have been
  14. inadequate policies, processes and practices to safeguard people in care
  15. inadequate policies, processes and practices, including reporting, to detect abuse and neglect
  16. people in care experiencing abuse and neglect, which has had ongoing impacts for survivors and their whānau
  17. inappropriate use of seclusion and restraint in psychopaedic and psychiatric settings and inappropriate use of medication, aversion practices, and shock treatment, and acts that met the Solicitor-General’s definition of torture
  18. failing to maintain accurate records, including not recording ethnicity, Deaf, disability or mental distress or impairment, compounded by the loss of records, has resulted in the true number of those in care will never be known.

Ngā takinga mātauranga | Education settings

Relevant Ministers, Secretaries and Chief Executives of Education were at fault for:
1. failing to provide education fit for different groups, including Blind, Deaf, and disabled children and young people
2. failing to support New Zealand Sign Language and the language and cultural needs of Deaf people
3. failing to identify and support the needs of neurodivergent people
4. ignoring Deaf and disabled peoples’ and communities’ perspectives and solutions
5. failing to actively protect te reo and encourage its use by Māori, which was in breach of te Tiriti o Waitangi, and has had an ongoing detrimental effect for Māori
6. not sufficiently valuing Māori culture
7. failing to respond to the identity, language, and culture of Māori which has been harmful, and contributed to poor education outcomes
8. having consistently lower expectations of tamariki and rangatahi Māori
9. having less oversight of private schools than state or state-integrated schools, which may have increased opportunities for abusers
10. failing to keep children safe, during the school day and in overnight/boarding care
11. failing to keep children in some schools and boarding facilities connected with whānau.

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

Successive Commissioners of NZ Police were at fault for:
1. negative Māori experiences with policing
2. failing to recognise the importance of te Tiriti o Waitangi until the mid-1970s
3. failing to understand the role of NZ Police in the disproportionate representation of Māori in the criminal justice system
4. NZ Police responses to Māori over-representation in the criminal justice system that fell short of a full commitment to the principles of te Tiriti o Waitangi
5. NZ Police responses that did not reflect the needs of Māori communities or the best way to resolve situations for Māori
6. failing to value tikanga Māori as part of policing practice, for most of the Inquiry period
7. Pacific Peoples’ negative experiences with policing
8. failing to understand whether ableism within NZ Police contributed to disproportionate representation of disabled people in the criminal justice system
9. inadequate policies, processes, and procedures to support Deaf and disabled people and people experiencing mental distress to engage with NZ Police
10. during the 1950s to 1970s, a singular focus on enforcement
11. during the 1950s to 1989, not consistently considering alternatives to criminal proceedings for children and young people
12. Before 1989, not being inclusive whānau in the decision-making impacting the person in their care
13. failing to consistently follow General Instructions and related policies regarding children, young people and adults in their care, such as questioning people under the age of 14 without the presence of any parent, guardian or lawyer
14. the use of police cells to detain children and young people (due to lack of alternatives), which was, and remains, unsuitable for children and young people, particularly those in care and protection
15. the abuse and neglect people experienced while in transitional and law enforcement settings, including physical abuse
16. failing to understand or investigate the nature and extent of police abuse of people in transitional and law enforcement care settings
17. General Instructions that limited who could access vetting during the Inquiry period, particularly between 1977 and 1991
18. lacking a universal policy on how to respond to allegations of abuse and neglect in care
19. before 1995, lacking a dedicated policy relating to investigation of sexual abuse and serious physical abuse of children
20. lacking awareness of the risk of sexual offending by people in positions of authority
21. negative bias against victims of abuse and neglect who were not believed or considered reliable or credible, for example at times assuming that Deaf and disabled people, and people experiencing mental distress may not be credible witnesses, or assuming promiscuity of a young survivor when investigating allegations of sexual abuse in care
22. failures to investigate abuse and neglect against children, young people and adults in care
23. lacking statistical data on allegations of abuse and neglect in care
24. the racism and discrimination exhibited by some leaders within NZ Police
25. failing to collect data on the diversity of the NZ Police workforce, specifically ethnicity and the number of Deaf or disabled police.

Ngā takinga a pūnaha taurima katoa | Whole of care system settings

Successive governments were at fault for:
1. institutional, structural racism and ableism in legislation, policy and systems that contributed to the disproportionate representation, and discriminatory treatment of Māori, Pacific Peoples, Deaf and disabled people, people experiencing mental distress, and Takatāpui, Rainbow and MVPFAFF+ people in care
2. the alienation of tamariki, rangatahi, and pakeke Māori from their whānau, hapū, and iwi, and their culture, identity, language, and the ongoing impacts of that alienation
3. the alienation of Pacific Peoples from their kainga, culture, identity, language, and the ongoing impacts of that alienation
4. the alienation of Deaf people from their whānau and communities, and their culture, identity, language, and the ongoing impacts of that alienation
5. the abuse and neglect people experienced while in care
6. failing to ensure that people in care were safe from abuse and neglect
7. failing to consistently stop abuse and neglect in care when it was disclosed or reported
8. record-keeping issues, including gaps and loss of records, which mean the true number and make up of children, young people and adults in care is unlikely to ever be known.
1. Successive State or Public Service Commissioners (responsible for the integrity and conduct of public servants, and the appointment and performance of chief executives) were at fault for failing to hold chief executives to account for:
  1. preventing abuse and neglect in care
  2. not adequately identifying and investigating abuse and neglect in care
  3. appropriately responding to complaints of abuse and neglect in care by both protecting people in care and holding abusers to account
  4. providing holistic redress for survivors of abuse and neglect in care
  5. addressing the role the public service played in being responsible for the abuse and neglect people experienced and the ongoing impacts of such abuse and neglect while in State care
  6. addressing the public servants not following the standards of successive codes of conduct
  7. the lack of a cohesive public service to provide joined-up, comprehensive and coherent safeguarding of children, young people and adults in care
  8. there being no appropriate public service framework for:
    - - ensuring the care workforce were diverse and reflected the makeup of society
        
        ensuring workplaces were inclusive of all groups in society
        
        focusing on developing and maintaining public service capability to engage with Māori and understand Māori perspectives.

Ngā whakapono | Faiths

The Catholic Church was at fault for:

the harm that has taken place in some Catholic educational institutions. That harm includes:
- - serious sexual harm and inappropriate physical punishment
  - inadequate steps taken in response to complaints of abuse and neglect
  - putting students at risk of harm by appointing abusers to the school without effective methods in place for protecting students
  - placing a heavy reliance on the opinions of psychiatrists in determining the ability of an abuser to rehabilitate and continue working in certain areas or in ministry, which resulted in abusers being transferred to other areas of ministry where re-offending occurred
being slow to act when sexual abuse was occurring
children being harmed in Catholic institutions where they should have been cared for and safe
harm caused to children because of mistakes made by the Church which could have and should have been avoided
not doing more to prevent the pain and suffering of all those who should have been kept safe in the church’s care
the following factors which caused abuse to occur or prevented its disclosure:
- - - prioritising forgiveness over safeguarding and accountability for those who perpetrated the abuse and the leadership at the time with knowledge of the abuse
    - creating a power imbalance between religious/clergy and their parishioners
    - lack of resources of, and investment in, those with the care of children, young people and adults (when they should not have been in those positions)
    - lack of training for those in care of children, young people and adults
    - care for the reputation of the church.

The Anglican Church was at fault for:
1. the failures of those within the Church who were meant to protect and care for people in their care
2. abuse and neglect in the care of the Church
3. abuse and neglect that included sexual abuse, physical abuse, verbal abuse and emotional abuse and neglect
4. perpetuating societal attitudes in its institutions, like corporal punishment, normalised bullying in schools, and suppressing Māori and Pacific Peoples’ culture
5. failing to implement institutional monitoring, leaving the responsibility of management up to individual leaders
6. failing to implement an overarching Church policy or process to guide the handling of complaints of abuse, including record-keeping
7. leaving allegations and complaints of abuse to be handled by those who knew the alleged abusers well, with some unwilling to accept a fellow clergy member could be an abuser
8. abuse that was ignored or covered up within the Church, which failed to protect people in care and failed to hold abusers to account
9. perpetrators of abuse who were protected by the sanctity of their role within Anglican institutions
10. failing to believe the survivor when they first came forward, instead survivors were often deemed untrustworthy or deceitful
11. survivors having to live with the consequences of the trauma they suffered for decades
12. the families of survivors having to carry the long-term consequences of abuse and neglect
13. the role of patriarchy within the Church in failing to listen and respond to issues of abuse and neglect
14. being too trusting of individuals within the Church, which contributed to the Church’s failure to address its mistakes sooner.

The Methodist Church was at fault for:
1. failing in its duty to ensure the protection and wellbeing of those in its care
2. the pain and suffering of all those who were abused in the Church’s care, including:
  - - - those who suffered abuse while at Wesley College
      - those who suffered abuse in former children’s homes, in Christchurch, Masterton, and Auckland
      - those who suffered abuse by a Minister, foster parents or in other Methodist Church parish settings
      - those who suffered abuse, which remains unreported
3. Abuse and neglect, including sexual, physical, emotional and psychological abuse and neglect
4. insufficient monitoring, oversight and safeguarding of those in their care, which enabled abuse to occur
5. failing to implement protection policies and procedures across all its Church-related entities
6. failing to implement mandatory NZ Police vetting
7. failing to consistently implement key changes on an “all of Church” approach to ensure those providing care were adequately trained and resourced
8. failings in addressing complaints, including not always accepting and acting appropriately on reports of abuse and complaints
9. responding to complaints with a traditional legal approach that included:
  - - - requiring survivors to report their abuse to NZ Police before conducting its own inquiries
      - declining to progress claims in a way that meant survivors had to pursue legal claims in the courts
      - failing to recognise it had a duty to take action to discipline a member of the Church, particularly a Minister
10. failing to recognise the Church’s role to deliver a restorative response to reports or complaints of abuse
11. the additional harm caused to survivors when the Church initially refused to believe them, sought to contest their concerns, or refer the complaint elsewhere, and failing to recognise the Church needed to address their complaint
12. the trauma experienced as a result of abuse, which has had long term impacts on the lives of survivors, their whānau and loved ones
13. failing to have record keeping policies relating to reports or complaints of abuse and neglect.
From Gloriavale's inception in 1969 through to the end of the Inquiry period, the Overseeing Shepherd and senior leadership of the Gloriavale Christian Community were at fault for:
1. allowing physical and sexual abuse to happen within the community
2. failing to address intergenerational sexual abuse within the community which perpetrated a cycle of harm
3. failing to prevent and protect survivors within the community against abuse
4. responding to allegations of abuse by seeking to create repentance from the offender and forgiveness from the victim
5. failing to recognise the harm of abuse on survivors
6. failing to deal with perpetrators of abuse appropriately, allowing them to continue living in the community and allowing abuse to continue within the congregation as a result
7. failing to recognise the scale and extent of abuse in the community
8. dealing with complaints of abuse themselves and not engaging any other authorities or professionals, including NZ Police or Oranga Tamariki and its predecessors
9. the role the community’s Doctrines had in creating a culture that allowed abuse to occur.
The Presbyterian Church were at fault for:
1. 1. its reluctance to confront abuse
  2. failing to remove people who posed risks to children, young people and adults in their care from unsupervised participation in the Church
  3. its reluctance to make binding rules
  4. failing to recognise ministers, elders or leaders as people who could cause harm
  5. its dynamic of protecting the congregation from outside interference, creating a risk of abuse and neglect
  6. discounting complaints of abuse
  7. failing to report complaints of abuse to proper Church authorities or to NZ Police, allowing perpetrators to continue abusing
  8. not supporting survivors to make complaints, making them feel isolated, discouraging them from taking complaints further and not believing them
  9. removing perpetrators from one area but allowing them to continue in other areas without considering the risks
  10. deliberately attempting to suppress reports of abuse at times
  11. failing to apply its policy of zero tolerance of abuse of people in the case of the Church consistently and thoroughly
  12. failing to consistently uphold its Code of Ethics in relation to pastoral care adopted in 1995
  13. failing to consistently report breaches of its Code of Ethics.
Additionally, Presbyterian Support Services Central was at fault for:
1. failing to properly record the ethnicities of Māori and Pacific children in the care of Berhampore Home
2. failing to prioritise any understanding of how to better deliver care to disabled people.
The Salvation Army was at fault for:
1. lack of understanding of the abuse and neglect of children, young people and adults in their care, and its effects on survivors, sometimes lasting for a lifetime
2. wide-ranging abuse and neglect in their care, which included sexual, physical and psychological abuse and neglect and mistreatment
3. abuse and neglect carried out by staff and officers of the Salvation Army, by other residents or visitors to homes, and foster parents and caregivers
4. abuse and neglect in their homes for unwed mothers, including Bethany homes, including pressure to have their children adopted, while being denied relevant information, medical and emotional help and support
5. abuse and neglect in children’s homes in Whakaoriori Masterton, Temuka, Tāmaki Makaurau Auckland, Putaruru, Eltham in Taranaki, Te Whanganui-a-Tara Wellington, and Kirikiriroa Hamilton
6. serious neglect in some children’s homes and homes for unwed mothers, including inadequate nutrition, hygiene and healthcare
7. abuse that included racism, ableism, and discrimination based on gender and sexuality.

Ngā roopu hunga mātanga | Professional bodies

The New Zealand Medical Association and Medical Council of New Zealand were at fault for:
1. actions that the New Zealand Medical Association and Medical Council of New Zealand should have taken, but did not, to protect the public
2. decisions in relation to complaints of abuse, that the Medical Council of New Zealand cannot now explain due to the incompleteness of records
3. the New Zealand Medical Association prioritising fairness to doctors (including psychiatrists) over the safety and wellbeing of patients when investigating complaints
4. accepting much of Dr Selwyn Leeks’ response to allegations without question when investigating a complaint against Dr Leeks in 1977.
The Nursing Council of New Zealand and its predecessors were at fault for not taking appropriate care of survivors, and their whānau, involved in its processes, resulting in unacceptable instances of harm. For some survivors, those processes have had a significant and ongoing impact.
The Teaching Council of Aotearoa New Zealand and its predecessors were at fault for not taking appropriate care of survivors, and their whānau, involved in its processes, resulting in unacceptable instances of harm. For some survivors, those processes have had a significant and ongoing impact.

Ngā akonga i kitea he mea panoni
Lessons identified and changes made

83. Clause 31(e) of the Terms of Reference requires the Inquiry to make findings on the lessons learned, and what changes were made to prevent and respond to abuse. The Inquiry finds:

Te hunga i te pū o ngā mahi tūkino | The people at the centre of abuse and neglect

The State made discrete changes to safeguard against abuse and neglect and increase protective factors for people in care during the Inquiry period, generally from the late 1980s onwards.
Some faith-based institutions began to introduce some safeguarding and protective factors from the late 1980s onward.
There were discrete changes to support the role of staff and carers in detecting and responding to abuse, mainly relating to training and voluntary reporting from the late 1980s onwards.

Ngā kawenga atawhai a ngā hinonga me ngā kāinga tamariki atawhai
The institutions and foster homes responsible for care

The State legislated for standards of care in some settings from the mid to late 1980s onwards.
The State made changes to regulate some staff in some care settings, such as teachers, and progressively developed policies in State settings on recruitment, vetting, training, development and supervision from the 1970 onwards.
The State introduced detailed regulations on complaints processes for people in social welfare residences and institutions in 1986 and people subject to a compulsory mental health assessment or treatment order in 1996.

Ngā kawenga atawhai ā-whakapono | The faiths responsible for care
Faith-based care settings either did not make changes or were slow to make changes to prevent and respond to abuse during the Inquiry period.

Ngā kawenga atawhai a te Kāwanatanga | The State’s responsibility for care
The State was slow to learn and act on critical lessons identified about abuse and neglect in care and many changes were not made until the 1980s onwards.
The State made many changes toward the end of the Inquiry period, including the creation of new legislation, policies and standards as new lessons were being identified and calls for change were being made.
The State made changes to prevent and respond to abuse and neglect with good intentions but these were not always realised due to implementation failures.
The State learned lessons about the impact of institutionalisation and segregation on Deaf and disabled people and people experiencing mental distress but was slow to take action in response.
The State learned lessons about the overrepresentation of Māori across all care settings, but changes were generally not made until the late 1980s to try to address this.
Changes made throughout the Inquiry period to prevent and respond to abuse and neglect were inconsistent across care settings.
Changes made were substantially smaller than the scale of abuse and neglect in care.
Many discrete policy changes were made to respond to abuse and neglect in Social Welfare settings.
Changes by the State were slow and few to prevent and respond to abuse and neglect in Deaf, disability and mental health settings.
The State did not make changes to prevent or respond to abuse and neglect in many faith-based settings during the Inquiry period.
Societal attitudes changed over the Inquiry period.
The State made some changes to try and eliminate discriminatory institutional policies and practices.