35. Part 7 of the Inquiry’s final report, Whanaketia – Through pain and trauma, from darkness to light, describes the factors that the Inquiry identified as having caused or contributed to the abuse and neglect of children, young people and adults in State and faith-based care. Part 7 also identifies the lessons learned and the changes made to prevent and respond to abuse and neglect. Part 7 concludes by setting out findings relating to:

• breaches of relevant standards
• factors that caused or contributed to abuse and neglect in care
• fault
• lessons learned.

36. The Inquiry identified that four factors all caused or contributed to the abuse and neglect of disabled survivors in State and faith-based care. These included:

• the factors relating to the people at the centre of abuse and neglect
• institutional factors
• structural and systemic factors
• societal factors.

37. Disabled people including whānau haua in State and faith-based care were diverse, with diverse care and support needs. Although each person in care was unique, every person needed support, strong protection, and safeguarding. Strong protection refers to a set of internationally-recognised factors that contribute to resilience because they promote healthy development and well-being and can reduce the risk
of experiencing abuse and neglect. These factors are a combination of personal, parental, and environmental factors.

38. The rights guaranteed in te Tiriti o Waitangi reinforce many protective factors. For example, connection to whakapapa, whānau, hapū and iwi are taonga protected by te Tiriti o Waitangi.

39. Had these rights been upheld during the Inquiry period – such as the right to tino rangatiratanga over kāinga, and the right to continue to live in accordance with indigenous traditions and worldview guaranteed by the principle of options – these rights would have been amplified protective factors for tamariki, rangatahi, and pakeke Māori, reducing entry into care and the risk of abuse and neglect in care.

40. Human rights recognise that children, young people, adults, people with disabilities and Māori as indigenous to Aotearoa New Zealand are distinct groups that also require special measures, particularly protective measures. In care settings, this means special protection measures like comprehensive standards of care needed to be in place. During the Inquiry period, the lack of special protections or measures for people in care were factors that contributed to abuse and neglect.

41. Many of these factors were exacerbated by societal attitudes that saw disabled people as ‘abnormal’ and less valuable than other people. These attitudes, and the consequent discrimination of disabled people, meant that disabled people were more likely to be placed into care, and more at risk of being abused and neglected while in care. Disabled people who were Māori, Pacific and / or Takatāpui, Rainbow or MVPFAFF+ experienced the compounding effects of racism and homophobia on top of ableism and disablism.

42. Chapter 6 of the Inquiry's Kimberley Centre case study, Out of Sight, Out of Mind, describes the factors that caused or contributed to abuse and neglect at the Kimberley Centre in Taitoko, Levin. 

43. Part 7 of the Inquiry’s final report, Whanaketia – Through pain and trauma, from darkness to light, includes more detailed information on the factors that caused or contributed to the abuse and neglect of disabled people in care:

• Chapter 2 describes the factors related to people in care, abusers and bystanders that contributed to abuse and neglect in care
• Chapter 3 explains that standards relevant to care (including te Tiriti o Waitangi Treaty of Waitangi and human rights protections) were inadequate, inconsistent and routinely breached
• Chapter 4 discusses the poor employment policies and practices that contributed to abuse and neglect in care, including failure to vet staff, inadequate recruitment and training, and under-resourcing
• Chapter 5 explains that complaints processes were absent or easily undermined, that survivors were often not believed if they reported abuse and neglect, and that senior leaders prioritised the reputations of institutions and abusers over the safety of people in care
• Chapter 6 explains that oversight and monitoring were ineffective
• Chapter 7 summarises the institutional, structural and systemic factors set out in Chapters 3–6 that contributed to abuse and neglect including there was little accountability for abuse and neglect.
• Chapter 8 describes the faith-specific factors that contributed to abuse and neglect, including ableism based on religious concepts
• Chapter 9 discusses the State’s responsibility for care, including that its highestlevel decision-makers rarely took accountability for abuse and neglect in care
• Chapter 10 explains that societal factors, including ableism and disablism, contributed to abuse and neglect in care.

Lessons identified and changes made

44. During the Inquiry period, the State attempted to make some changes to address problems identified in different care settings and to prevent and respond to abuse and neglect in State and faith-based care.

45. Most changes were specific to certain care settings. These changes included the creation of new legislation, policy, rules, standards and practices to prevent and respond to abuse and neglect in care as well as subsequent tweaks to these regulations, as new lessons were learned. Several of these changes had a positive impact on people in care, while some had intentions that were not achieved in practice.

46. Legislative and policy changes can largely be seen as a good faith attempt by the State to address lessons identified and to respond to and mitigate abuse and neglect in care. With hindsight, much more abuse and neglect could have been prevented if changes had been applied consistently across all settings and implemented differently. The changes often reflected discrete elements of a lesson, which limited their potential impact for preventing and responding to abuse and neglect in care.

47. Implementation repeatedly frustrated successful change. Common failures of implementation included funding and resourcing constraints, and lack of diversity in leadership positions, policy design and service delivery.