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, 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 people, 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:
- entry into care caused trauma
- psychological and emotional abuse and neglect
- physical abuse and neglect
- sexual abuse racial abuse and cultural neglect
- spiritual and religious abuse and neglect
- medical abuse and neglect
- solitary confinement
- financial abuse and forced labour
- 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:
- 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
- abuse and neglect were particularly prevalent in social welfare settings, faith settings (particularly Catholic, Anglican, and Gloriavale) and disability and mental health settings
- 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
- tamariki, rangatahi and pakeke Māori were more likely to experience neglect compared to non-Māori children, young people, and adults in care
- children aged 10-14 endured high levels of sexual and physical abuse
- Māori and Pacific survivors endured higher levels of physical abuse than other ethnicities
- disabled survivors suffered higher levels of all forms of abuse than non-disabled survivors
- Deaf and disabled survivors were more likely to report physical, emotional, and sexual abuse than other forms of abuse
- 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
- children and young people in foster care experienced the highest levels of sexual abuse among social welfare care settings
- the decade with the highest rates of abuse and neglect was the 1970s, followed by the 1960s and then the 1980s
- some survivors reported the misuse of solitary confinement or seclusion
- male survivors reported higher levels of abuse than females, including sexual abuse. Males experienced higher levels of physical abuse than other forms of abuse
- 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.
- 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
- At the Lake Alice Child and Adolescent Unit, as set out in the Inquiry's interim report Beautiful Children, abuse included:
- electric shocks and injections of paraldehyde as punishment, administered to various parts of the body including the head, torso, legs and genitals
- the misuse of solitary confinement
- 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:
- abuse and neglect was extensive and extreme
- sexual abuse was pervasive
- physical, emotional, and psychological abuse led to some survivors living in perpetual fear
- evidence suggests the abuse was used as punishment as well as to intimidate
- there was pervasive neglect including neglect of basic needs as well as cultural, medical, and emotional needs
- children and young people suffered mental and physical pain
- cultural and religious abuse was extensive
- 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:
- abuse and neglect were pervasive and extreme
- young people experienced severe physical violence
- young people were sent alone to an isolated island for days at a time as punishment
- 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:
- disabled children, young people and adults suffered severe and chronic abuse and neglect
- physical and sexual abuse of disabled children, young people and adults was pervasive and severe
- 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
- people experienced extreme neglect of their physical, emotional, psychological, educational, medical, and dental needs
- 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
- 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
- disabled children, young people and adults suffered severe and chronic abuse and neglect
- 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:
- Deaf students experienced regular sexual, physical, verbal and psychological abuse
- physical violence was normalised and pervasive
- all Deaf children and young people experienced linguistic abuse, and neglect and language suppression
- 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:
- there were cultures of normalised and pervasive violence, with many experiencing severe corporal punishment, sometimes inflicted with weapons and to the genitals
- staff condoned and encouraged peer-on-peer violence through a king-pin system including violent 'stomping' initiations of new boys
- sexual abuse was pervasive
- solitary confinement was misused
- racism and cultural abuse was normalised
- 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:
- difficulty with establishing intimate relationships
- difficulty with maintaining family relationships
- devastating effects on their health and wellbeing
- damaged mental health and emotional wellbeing
- lack of education opportunities impacting on ability to participate in society
- reduced opportunities for gaining and maintaining employment opportunities
- increased financial insecurity
- experiencing periods of homelessness
- reduced trust in authority
- for some, pathways into addiction
- for some, pathways into sex work
- for some, pathways into criminality and prison
- for some, pathways into gang membership
- for some, entrapped in institutional care
- struggles with sexuality and gender identity
- For Māori survivors in addition to the impacts outlined above, they experienced:
- disconnection from whakapapa and te ao Māori
- loss of identity as Māori, te reo, tikanga and matauranga Māori
- 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 consider are normal day-to-day activities is estimated to be approximately $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 $96 billion and $217 billion, of which the smallest proportion is paid by the taxpayers of New Zealand, up to $46.7 billion. The largest cost, estimated up to $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
- 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 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.
- 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 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 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 failed to provide appropriate redress for those who suffered abuse and neglect.
Ngā takahi i ngā paerewa atawhai | Breaches of standards of care
-
- People in care had rights to standards of care that prevented abuse (ill-treatment) and neglect during the Inquiry period. However:
- in some settings, particularly disability and mental health, education and faith, the government failed to set adequate or overarching standards of care
- in Deaf, disability and mental health settings, institutions breached the standards they set, specifically, survivors' rights to dignity, respect, and proper daily care and to adequate protection from abuse, neglect and exploitation
- 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)
- 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.
- in some settings, particularly disability and mental health, education and faith, the government failed to set adequate or overarching standards of care
- There were regular and routinely breaches of standards of care with significant impacts for many children, young people and adults in care.
- 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.
- 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.
- Breaches of standards of care included:
- neglect and abuse (ill-treatment), including sexual abuse, that was severe, extensive, extreme or pervasive in some institutions
- wrongful use of seclusion, solitary confinement and secure care
- frequent use of corporal punishment, which at times was extreme and perverse punishment involving weapons and humiliation.
- 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.
- the failure of some social workers to visit State wards in care, a key intervention and rescue point for people experiencing abuse or neglect
- lobotomies, sterilisation, forced adoptions, invasive genital examinations, over medicating, and experimental psychiatric treatments without informed consent
- 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.
- neglect and abuse (ill-treatment), including sexual abuse, that was severe, extensive, extreme or pervasive in some institutions
Ngā take i hua ai te mahi tūkino i ngā pūnaha taurima
Factors that caused or contributed to abuse and neglect in care79. 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. In summary, the Inquiry finds that, during the Inquiry period:
Te hunga i te pū o ngā mahi tūkino| The people at the centre of abuse and neglect
-
-
- Children, young people, and adults in care were diverse, with different care and support needs.
- Children, young people, and adults in care needed support, protection, and safeguarding when in care.
- Strong protective factors significantly reduce the risk of abuse and neglect and the likelihood of entry into care.
- Many people entering care had weakened protective factors, contributing to the risk they would experience abuse and neglect
- Many of the circumstances that made it more likely a person would enter care often became the circumstances that made them more susceptible to abuse and neglect in care.
- 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.
- Abusers were often predatory.
- Abusers exploited the powerlessness and vulnerability of those they were abusing or neglecting.
- Abusers often acted with impunity.
- 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.
- Most abusers took steps to conceal their actions. They ensured that survivors&rsquo complaints about abuse and neglect were ignored or suppressed.
- Many abusers avoided accountability, allowing them to abuse for extended periods and across multiple residences and institutions.
- Many bystanders (staff, volunteers and carers) failed to stop or report abuse and neglect that they observed or suspected was occurring.
- Children, young people, and adults in care were diverse, with different care and support needs.
Take hinonga | Institutional factors
- The following institutional factors contributed to abuse and neglect in care:
- 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
- individual care needs were not routinely or accurately identified, recorded and met
- 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.
- poor or inadequate vetting policies, exacerbated by a lack of access to NZ Police vetting for most settings
- 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 prioritising abusers&rsquo 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
- barriers faced by people in care to raise concerns or complaints, including a lack of access to whānau, communities, and advocates
- ineffective, ad hoc and insufficient oversight and monitoring, which did little to prevent or respond to instances of known abuse and neglect
- consistent accountability failures, that allowed abuse and neglect to continue and gave many abusers a sense of impunity.
- 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
- 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:
- legislation specific to care settings to give effect to the guarantees made to Māori in te Tiriti o Waitangi, particularly tino rangatiratanga
- legislation specific to care settings to respect, protect and fulfil the human rights of people in care
- 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
- steps to minimise and ultimately end institutionalised environments and practices
- 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
- best practice training and development standards for staff and carers
- independent, strategic, well-funded independent oversight and monitoring that looked across all care settings and consistently reported abuse and neglect to NZ Police.
- legislation specific to care settings to give effect to the guarantees made to Māori in te Tiriti o Waitangi, particularly tino rangatiratanga
-
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 authority and impunity of faith-based institutions created opportunities for abuse and neglect to occur and continue.
- Discriminatory attitudes, policies and practices that contributed to abuse and neglect.
- 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:
-
- people in care, whānau and communities had limited input into State decisions about care
- the State's attempts to deal with institutional discrimination, which impacted who went into care and who experienced abuse and neglect in care, were lacklustre
- legislative and policy settings were discriminatory, underpinned by societal attitudes like racism, ableism and disablism, sexism, homophobia and transphobia, negative stereotypes of children and young people as delinquents, and negative attitudes towards people living in poverty
- 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
- the State did not give effect to rights guaranteed in te Tiriti o Waitangi, particularly tino rangatiratanga
- the State lacked diversity and lived experience of care in its leadership
- the State did not ensure people in care were safeguarded from abuse or neglect, or had effective oversight and monitoring
- there was a lack of State accountability for abuse and neglect, particularly those with statutory responsibilities to people in care
- the State did not ensure there was a comprehensive regulatory care framework that was enforced, properly invested in and resourced
- the State failed to respond to signs of systemic abuse and neglect, taking no steps to understand if its system of care was failing
- 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:
-
- legislation specific to care settings to give effect to the guarantees made to Māori in te Tiriti o Waitangi, particularly tino rangatiratanga
- legislation specific to care settings to respect, protect and fulfil the human rights of people in care
- 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
- steps to minimise and ultimately end institutionalised environments and practices
- 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.
- 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
- best practice training and development standards for staff and carers.
- 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:
- 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.
- negative views about people living in poverty and welfare dependency
- belief systems that upheld reverence and trust in faith-based institutions and members of faith
- negative views towards children and young people, as delinquents, naughty, and not to be believed
- society condoned and tolerated institutionalisation of people for decades
- 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.
- The following societal factors contributed to abuse and neglect in care:
- legislation specific to care settings to give effect to the guarantees made to Māori in te Tiriti o Waitangi, particularly tino rangatiratanga
Whakatau hē | Findings of fault
80. 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:
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 Executives of the Department of Social Welfare and its successors were at fault for:
- not consistently supporting whānau to prevent people from entering care, including insufficiently emphasizing whānau-based alternatives to State care
- often ignoring Māori perspectives and solutions
- failing to properly vet, train, support, and monitor caregivers in social welfare settings
- failing to consistently believe or follow up on reports of harm in social welfare settings.
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:
- implementing institutionalisation policies from the 1950s to 1970s, despite WHO and the 1959 Burns Report warnings, led to the abuse and neglect of Deaf, disabled, and mentally distressed individuals
- ignoring disabled people's perspectives and solutions, hindering their autonomy in decision-making, not providing adequate support for families and lack of emphasis on non-institutional care options
- overrepresentation in care negatively impacting Māori, Pacific Peoples, Deaf, disabled, and mentally distressed individuals
- inappropriate practices like seclusion and restraint, contributing to abusive environments.
- implementing institutionalisation policies from the 1950s to 1970s, despite WHO and the 1959 Burns Report warnings, led to the abuse and neglect of Deaf, disabled, and mentally distressed individuals
Ngā takinga mātauranga | Education settings
- Relevant Ministers, Secretaries, and Chief Executives of Education were at fault for:
- failing to provide appropriate education for Blind, Deaf, and disabled children and young people
- failing to support New Zealand Sign Language and the cultural needs of Deaf people
- failing to actively protect and encourage the use of te reo Māori and consistently having lower expectations of tamariki and rangatahi Māori
- having less oversight of private schools compared to State or State-integrated schools, potentially increasing opportunities for abuse and neglect
- failing to keep children safe during the school day and in overnight/boarding care
- failing to keep children in some schools and boarding facilities connected with their whānau.
- failing to provide appropriate education for Blind, Deaf, and disabled children and young people
Ngā takinga whakatika mauhere ā-ture | Transitional and law enforcement settings
- Successive Commissioners of NZ Police were at fault for:
- failing to address NZ Police's role in the disproportionate representation of Māori in the criminal justice system
- negative experiences of Pacific Peoples with policing
- insufficient policies and procedures to support Deaf and disabled people, and those experiencing mental distress, in their interactions with NZ Police
- failing to consistently follow policies regarding the treatment of children, young people, and adults, including improper questioning of minors
- using police cells to detain children and young people, which was unsuitable for their needs
- negative bias against victims of abuse and neglect, particularly Deaf and disabled people, and those with mental distress
- failures to investigate abuse and neglect against individuals in care.
- failing to address NZ Police's role in the disproportionate representation of Māori in the criminal justice system
Ngā takinga a pūnaha taurima katoa | Whole of care system settings
- Successive governments, including Ministers, were at fault for:
- institutional and structural racism and ableism in legislation, policies, and systems, leading to the disproportionate representation and discriminatory treatment of marginalised groups including Māori, Pacific Peoples, Deaf and disabled people, people experiencing mental distress, and Takatāpui, Rainbow, and MVPFAFF+ people
- alienating Māori (tamariki, rangatahi, and pakeke) from their whānau, hapū, iwi, and their culture, identity, and language, with ongoing detrimental impacts
- alienating Pacific Peoples from their kainga (family), culture, identity, and language, with ongoing detrimental impacts
- alienating Deaf people from their whānau and communities, culture, identity, and language, with ongoing detrimental impacts
- allowing abuse and neglect of people in care
- failing to ensure the safety of people in care from abuse and neglect
- inconsistently addressing disclosed or reported abuse and neglect in care
- record-keeping issues, including gaps and loss of records, making it difficult to know the true number and makeup of children, young people, and adults in care.
- institutional and structural racism and ableism in legislation, policies, and systems, leading to the disproportionate representation and discriminatory treatment of marginalised groups including Māori, Pacific Peoples, Deaf and disabled people, people experiencing mental distress, and Takatāpui, Rainbow, and MVPFAFF+ people
- 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:
- not 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
- not appropriately responding to complaints of abuse and neglect in care by both protecting people in care and holding abusers to account
- not providing holistic redress for survivors of abuse and neglect in care
- not addressing public servants not following the standards of successive codes of conduct
- the lack of a cohesive public service to provide joined-up, comprehensive and coherent safeguarding of children, young people and adults in care
- 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.
- not 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
Ngā whakapono | Faiths
Te Hāhi Kātorika o Aotearoa | Catholic Church in Aotearoa New Zealand
- The Catholic Church in Aotearoa New Zealand and related Catholic entities were at fault for:
- inadequate responses to complaints of abuse and neglect
- appointing abusers to schools without effective protective methods in place
- relying heavily on psychiatrists' opinions, leading to transferring abusers to other areas of ministry where they re-offended
- prioritising forgiveness over safeguarding and accountability
- creating a power imbalance between clergy and parishioners
- lack of resources and investment in those caring for children and vulnerable individuals
- prioritising the Church&rsquos reputation over safety.
- inadequate responses to complaints of abuse and neglect
Te Hāhi Mihinare o Aotearoa me te Moana-nui-a-Kiwa | Anglican Church in Aotearoa New Zealand and Polynesia
- The Anglican Church in Aotearoa New Zealand and Polynesia was at fault for:
- promoting corporal punishment, normalising bullying in schools, and suppressing Māori and Pacific Peoples' culture
- failing to implement monitoring and leaving management to individual leaders
- allowing complaints to be managed by those familiar with the alleged abusers, with some unwilling to accept a fellow clergy member could be an abuser
- failing to protect people and hold abusers accountable by ignoring or covering up abuse. Perpetrators were shielded by the sanctity of their roles within the Church
- disbelieving survivors initially and labelling them as untrustworthy or deceitful.
- promoting corporal punishment, normalising bullying in schools, and suppressing Māori and Pacific Peoples' culture
Te Hāhi Weteriana o Aotearoa | Methodist Church of New Zealand
- The Methodist Church of New Zealand was at fault for:
- the pain and suffering of those who suffered sexual, physical, emotional, and psychological abuse and neglect in Church settings, including Wesley College, former children&rsquos homes, and by ministers or foster parents
- not implementing protection policies or mandatory police vetting across Church entities
- failing to consistently implement key changes on an "all of Church" approach to ensure those providing care were adequately trained and resourced
- using a traditional legal approach to claims including requiring police reporting, declining to progress claims meaning survivors had to pursue legal claims in the courts, and not disciplining Church members, including ministers
- not delivering a restorative response to abuse reports or complaints
- causing additional harm by initially disbelieving survivors, contesting their concerns, and failing to address complaints.
- the pain and suffering of those who suffered sexual, physical, emotional, and psychological abuse and neglect in Church settings, including Wesley College, former children&rsquos homes, and by ministers or foster parents
Hāhi Hāpori Karaitiana o Gloriavale | Gloriavale Christian Community
- 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:
- allowing physical and sexual abuse to happen within the community, failing to prevent abuse and protect survivors, and failing to recognize the harm inflicted on survivors
- responding to abuse allegations by seeking repentance from offenders and forgiveness from victims
- inappropriately handling perpetrators, allowing them to remain in the community and continue abusing
- handling abuse complaints internally without involving external authorities like NZ Police or Oranga Tamariki
- creating a culture through the community&rsquos Doctrines that allowed abuse to occur.
- allowing physical and sexual abuse to happen within the community, failing to prevent abuse and protect survivors, and failing to recognize the harm inflicted on survivors
Te Hāhi Perehipitiriana o Aotearoa me te Pokapū Tautoko o te Hāhi Perehipitiriana | Presbyterian Church of Aotearoa New Zealand and Presbyterian Support Services Central
- The Presbyterian Church of Aotearoa New Zealand were at fault for:
- reluctance to make binding rules
- protecting the congregation from outside interference, increasing abuse and neglect risks
- suppressing abuse reports at times, and failing to report abuse complaints to Church authorities or NZ Police
- not supporting survivors in making complaints, isolating them, and disbelieving them
- moving perpetrators without considering risks, allowing continued abuse
- inconsistently applying a zero-tolerance abuse policy
- failing to consistently uphold and report breaches of its Code of Ethics.
- reluctance to make binding rules
- Additionally, Presbyterian Support Services Central was at fault for:
- improperly recording the ethnicities of Māori and Pacific children in the care of Berhampore Home
- not prioritising better care for disabled individuals.
- improperly recording the ethnicities of Māori and Pacific children in the care of Berhampore Home
Te Ope Whakaora o Aotearoa, Whīti, Tonga me Hāmoa | The Salvation Army New Zealand, Fiji, Tonga and Samoa Territory
- The Salvation Army New Zealand, Fiji, Tonga and Samoa Territory was at fault for:
- wide-ranging sexual, physical, psychological abuse and neglect, including by Salvation Army staff, officers, residents, visitors, foster parents, and caregivers
- abuse involving racism, ableism, and discrimination based on gender and sexuality
- mistreatment in homes for unwed mothers, including pressure for adoption without relevant information or support
- abuse and neglect in various children&rsquos homes across multiple locations and serious neglect in some children's and unwed mothers' homes, including inadequate nutrition and healthcare.
- wide-ranging sexual, physical, psychological abuse and neglect, including by Salvation Army staff, officers, residents, visitors, foster parents, and caregivers
Ngā akonga i kitea he mea panoni
Lessons identified and changes made81. 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. In summary, the Inquiry finds that, during the Inquiry period:
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 from the late 1980s onwards.
- Some faith-based institutions began introducing safeguarding measures from the late 1980s.
- There were discrete changes to support staff and carers in detecting and responding to abuse, primarily through training and voluntary reporting from the late 1980s onwards.
- The State made discrete changes to safeguard against abuse and neglect 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.
- From the 1970s, the State regulated some staff in care settings and developed policies on recruitment, vetting, training, development, and supervision.
- In 1986, the State introduced detailed regulations on complaints processes for people in social welfare residences and institutions, and in 1996 for those under compulsory mental health assessments or treatment orders.
Ngā kawenga atawhai ā-whakapono | The faiths responsible for care
- Faith-based care settings were slow or did not 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 about abuse and neglect, with many changes occurring only from the 1980s onwards.
- Towards the end of the Inquiry period, the State made many changes, including new legislation, policies, and standards.
- Despite good intentions, the State&rsquos efforts to prevent and respond to abuse and neglect often failed due to implementation issues.
- The State recognised the over-representation of Māori in care settings but generally did not make changes until the late 1980s.
- Changes to prevent and respond to abuse and neglect were inconsistent across care settings.
- The scale of changes made was substantially smaller than the extent of abuse and neglect in care.
- Many discrete policy changes were made in social welfare settings to address abuse and neglect.
- Changes by the State were slow and few 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.
- The State made some efforts to eliminate discriminatory institutional policies and practices.
- not consistently supporting whānau to prevent people from entering care, including insufficiently emphasizing whānau-based alternatives to State care
- people in care, whānau and communities had limited input into State decisions about care
- People in care had rights to standards of care that prevented abuse (ill-treatment) and neglect during the Inquiry period. However: