471. 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.

472. The Inquiry identified that four factors all caused or contributed to the abuse and neglect of tamariki, rangatahi and pakeke Māori in State and faith-based care. These included:

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

473. Most of these factors did not have a significantly different effect on Māori compared with non-Māori in care. Two factors did have a significant and compounding effect on tamariki, rangatahi and pakeke Māori in care – the Crown’s failure to uphold the rights of Māori in care that were guaranteed in te Tiriti o Waitangi, and the institutional and structural racism embedded in the care system.

The people at the centre of abuse and neglect

Protective factors can reduce the risk of abuse and neglect

474. Strong ‘protective factors’ refers to a set of internationally recognised factors that contribute to resilience because they promote healthy development and wellbeing and can reduce the risk of experiencing abuse and neglect.[458]These factors are a combination of personal, parental and environmental factors. People have strong protective factors if they:[459]

• maintain strong connections with family, kāinga, whānau, hapū, iwi and community
• have good self-esteem or personal confidence and understand who they are and their place in the world
• for Māori, have full authority over their kāinga (home, residence or village) to live as Māori, and connection to their whakapapa, whānau, hapū and iwi
• have family cohesion and parental resilience
• have supportive and trustworthy peers and adults in their lives (in addition to their direct carers)
• understand their rights and how they should be treated
• understand appropriate and inappropriate behaviour, personal safety and what they can do in difficult situations.

475. Strong protective factors in whānau, children, young people and adults significantly reduces the likelihood of entry into care. In care  settings, protective factors can reduce the risk of abuse and neglect and increase a person’s resilience and ability to navigate difficult situations.[460]

Rights guaranteed in te Tiriti o Waitangi protect tamariki, rangatahi and pakeke Māori

476. 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. In addition, te Tiriti rights themselves protect Māori.

477. 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 worldviews, which is guaranteed by the principle of options – these rights would have been powerful protective factors for tamariki, rangatahi, and pakeke Māori, reducing entry into care and the risk of abuse and neglect in care.

478. The Inquiry heard how many whānau, hapū and iwi were not empowered to care for and raise their tamariki, rangatahi or pakeke Māori as guaranteed to them in te Tiriti o Waitangi.[461]When tamariki, rangatahi and pakeke Māori were removed from their whānau, hapū and iwi and placed into care, it removed the ability and power of whānau, hapū and iwi to care for and nurture the next generation, to regulate the lives of their people and to transfer mātauranga Māori.

479. The ongoing, intergenerational effects of colonisation and continuing assimilation policies and urbanisation during the Inquiry period meant that many tamariki, rangatahi and pakeke Māori did not have an understanding of who they were and their place in the world. Some had connections with their whakapapa, whānau, hapū and iwi severed. Many held shame or mamae, rather than pride in their culture.

480. The Crown’s failure to uphold these rights during the Inquiry period was a breach of the principles of tino rangatiratanga, kāwanatanga, partnership, active protection, and options.

Human rights protect tamariki, rangatahi and pakeke Māori

481. Human rights recognise that tamariki, rangatahi, pakeke Māori, whānau haua 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.

Factors for entry into care became factors for abuse and neglect in care

482. During the Inquiry period, many whānau and communities needed support to care for their children, young people and adults at home or within their community. Without this support, many children, young people and adults were placed in State and / or faith-based institutions.

483. People placed in care needed support, strong protection and to be safeguardedagainst abuse and neglect. Instead, many were placed in care facilities with institutional environments and practices that heightened the risk of abuse and neglect.

484. Many of the personal circumstances that made it more likely a child, young person or adult would enter care often made them more susceptible to, or put them at an increased risk of, abuse and neglect in care. These factors were underpinned by societal attitudes like discrimination based on racism, ableism, disablism, sexism, homophobia and transphobia, and negative stereotypes about children and young people, poverty and welfare dependency.

485. These factors included:

• being raised in poverty and experiencing deprivation
• being disabled with unmet needs
• being Māori and racially targeted
• being Pacific and racially targeted
• being Deaf with unmet needs
• experiencing mental distress with unmet needs
• being Takatāpui, Rainbow, MVPFAFF+, gender diverse or transgender and being targeted
• if a person had experienced significant or multiple adverse childhood events before entering care
• having a deferential attitude to people in positions of authority, including faith leaders and medical professionals
• other reasons such as age or gender.

486. Most survivors had or experienced many of these factors, which heightened the risk of abuse and neglect. For tamariki, rangatahi and pakeke Māori in care, this meant that they were more susceptible to abuse and neglect if they were also raised in poverty, were Pacific, Deaf or disabled or experienced mental distress, were Takatāpui, or had multiple combinations of these circumstances.

487. Abusers were a key factor that contributed to abuse and neglect in care. Abusers misused their positions of power and control over people in care to inflict at times extreme and violent abuse, or to neglect people in their care. Abusers sometimes took calculated steps to conceal their actions which allowed them to continue, at times, acting with impunity.

488. Many staff and carers who witnessed abuse and neglect, or were told about it, did nothing. Some bystanders did complain or raise concerns, but often with limited success.

Institutional, structural and systemic factors contributed to abuse and neglect in care

489. Part 7 of the Inquiry’s final report, Whanaketia – Through pain and trauma, from darkness to light, describes the institutional, structural and systemic factors that contributed to abuse and neglect in care during the Inquiry period. In summary, these factors included:

• standards of care were inconsistent and routinely breached
• poor or absent vetting exposed people in care to abusers
• inadequate recruitment, training and resourcing contributed to abuse and neglect
• complaints processes were absent or easily undermined, with few records kept
• senior State and faith leaders prioritised the reputations of institutions and abusers over people in care
• oversight and monitoring was ineffective
• rights guaranteed under te Tiriti o Waitangi and human rights were largely absent
• people in care were dehumanised and denied dignity
• people in care were isolated from whānau, kāinga, communities and advocates
• there was little accountability for abuse and neglect.

Te Tiriti o Waitangi was absent from standards of care, employment practices, complaints processes, and oversight and monitoring

490. The Inquiry considered te Tiriti o Waitangi in its examination of standards of care, employment policies and practices, complaints processes, and oversight and monitoring in State and faith-based care during the Inquiry period.

Te Tiriti o Waitangi was absent from standards of care

491. Throughout the Inquiry period, there was no legislative direction that standards of care should give effect to the rights guaranteed to iwi and hapū in te Tiriti o Waitangi or incorporate te Tiriti o Waitangi itself. It was left to government agencies and individual institutions to decide whether and how to incorporate te Tiriti o Waitangi into their standards of care. The Inquiry did not see any standards of care that explicitly incorporated te Tiriti o Waitangi or gave effect to the rights of iwi and hapū as expressed in te Tiriti o Waitangi, such as the right to exercise tino rangatiratanga, or that explicitly provided for te Tiriti principles of partnership, active protection, or equity.

492. Up until the late 1980s the Crown and government agencies developed standards of care without hapū or iwi input, undermining both tino rangatiratanga and te Tiriti o Waitangi principle of partnership. This represented a missed opportunity to incorporate tikanga Māori and Māori models of care into standards that reflected te ao Māori, mātauranga Māori, tikanga and te reo Māori, and to ensure connections to culture and to whānau, hapū and iwi were maintained. The Inquiry did not see any evidence of standards of care that sought to achieve equitable outcomes for tamariki, rangatahi and pakeke Māori in care, despite the fact that the overrepresentation of Māori in care settings was a known issue from the 1960s and Māori were the majority in social welfare care settings. This was a breach of both the active protection and options principles of te Tiriti o Waitangi, which arises from te Tiriti’s guarantee to Māori of both tino rangatiratanga and the rights and privileges of British citizenship under article 3.[462]

493. The Inquiry did observe that from the mid-1980s onwards there were some attempts made to include aspects of te ao Māori, tikanga Māori and te reo Māori in some care settings.

Te Tiriti o Waitangi was absent in employment policies, practices

494. Throughout the Inquiry period, there was no legislative direction that employment policies or practices should give effect to the rights guaranteed to iwi and hapū in Te Tiriti o Waitangi or incorporate Te Tiriti o Waitangi. It was left to government agencies and individual institutions to decide whether to incorporate Te Tiriti into their employment policies and practices. This includes policies and practices regarding vetting, recruitment, training and development of staff and other carers, the development of which could be seen as the Crown and government agencies expressing kāwanatanga. However, the Crown has an obligation to foster tino rangatiratanga, and unilateral expressions of kāwanatanga only serve to undermine tino rangatiratanga.[463]

495. The Inquiry did not see any employment policies or practices that explicitly incorporated te Tiriti o Waitangi or gave effect to the rights of hapū and iwi as expressed in te Tiriti o Waitangi. The State was aware from at least 1982 that there was a lack of diversity in the public service, and that recruitment and training programmes were needed to increase diversity and appoint people directly into positions of seniority and responsibility.[464]That this was not effectively addressed represents a missed opportunity to benefit from the Māori thinking, approaches and values that greater involvement of Māori employees in care settings and policy agencies would have brought. This was contrary to te Tiriti o Waitangi principles of tino rangatiratanga, partnership, active protection, good government, and options.[465]

Te Tiriti o Waitangi was absent in complaints processes

496. Throughout the Inquiry period, there was no legislative direction that complaints processes should give effect to the rights guaranteed to iwi and hapū in Te Tiriti o Waitangi. Despite the disproportionate numbers of tamariki, rangatahi and pakeke in care, complaints processes during the Inquiry period were not developed in partnership with iwi, hapū or whānau, to embed tikanga and te ao Maori into complaints processes for tamariki, rangatahi and pakeke.

497. The lack of culturally appropriate complaints processes for tamariki, rangatahi and pakeke throughout the Inquiry period demonstrates a lack of concern for, and a failure to actively protect, Māori in care.

Te Tiriti o Waitangi was absent in oversight and monitoring

498. From 1950 to 1976, there was no independent oversight or monitoring of breaches of the rights guaranteed in te Tiriti o Waitangi in State care settings.

499. From 1975 the Waitangi Tribunal had jurisdiction to enquire into claims regarding Crown acts that were inconsistent with te Tiriti o Waitangi and its principles after 1975. From 1985 this was extended to include historical claims dating back to 1840.[466]The Tribunal was first led by the Chief Judge of the Māori Land Court. Edward Taihakurei Junior Durie (Rangitāne, Ngāti Kauwhata, Ngāti Raukawa) was the first Judge of Māori descent to be appointed in 1980. He held the position until 1998 when Joseph Victor Williams (Ngāti Pūkenga, Waitaha, Tapuika) was appointed.[467]

500. There was a lack of Maōri leadership in other oversight and monitoring bodies between 1950 and 1999. The issues the Inquiry has identified with lack of robust and independent monitoring of care settings meant that the range and scale of abuse and neglect experienced by tamariki, rangatahi and pakeke Māori in care was not as visible as it could otherwise have been. It also meant that disparities in the extent and nature of abuse and neglect experienced by Māori were not revealed. This was a breach of the Crown’s obligations of active protection, equity and equal treatment, and good government. The failure in oversight and monitoring was part of the failure to adequately care for Māori, obtain and maintain adequate information or knowledge of any abuse or neglect suffered by Māori while in care, or hold abusers to account.

Rights guaranteed in te Tiriti o Waitangi were absent in care settings

501. From 1950 to 1999, the rights guaranteed to Māori in te Tiriti o Waitangi were almost always absent across care settings. The Inquiry saw no explicit references to tino rangatiratanga or te Tiriti o Waitangi itself in legislation that applied to care settings nor in standards of care, employment policies, or complaints processes, or in how oversight and monitoring was designed or implemented.

502. The Crown made guarantees to Māori in te Tiriti o Waitangi that were directly relevant to care settings. This includes the guarantee to Māori of tino rangatiratanga and the principles of partnership, active protection, options, and good government. These obligations were often not met.

503. The State did legislate changes specific to whānau, hapū and iwi in most care settings(excluding faith-based care and transitional and law enforcement settings) from the 1980s.[468]However, none of these changes used the language in te Tiriti o Waitangi, or referred to te Tiriti o Waitangi, or considered the pre-existing rights of Māori affirmed by te Tiriti o Waitangi, or incorporated the expanse of authority guaranteed to Māori.

504. The State care system is based on an assumption that the State has an innate responsibility to operate a care system for those deemed to be in need of care, including tamariki, rangatahi and pakeke Māori. This assumption fails to acknowledge the fundamental right of tino rangatiratanga over kāinga guaranteed to Māori by te Tiriti o Waitangi and does not recognise “the Crown’s sustained intrusion into the rangatiratanga of Māori over kāinga”.[469]This assumption also fails to acknowledge the compounding factors that contributed to Māori being overrepresented in care, including the ongoing impacts of colonisation. This is encapsulated in the Waitangi Tribunal’s He Pāharakeke, He Rito Whakakīkīnga Whāruarua report:

“The signatories to the Treaty did not envisage any role for the Crown as a parent for tamariki Māori, let alone a situation where tamariki Māori would be forcefully taken into State care – in numbers vastly disproportionate to the numbers of non-Māori children being taken into care.”[470]

The State’s responsibility for the care system and people in care

505. The State was ultimately responsible for safeguarding all people in care, regardless of the care setting, and preventing and responding to abuse and neglect. It was the State, for the most part, who decided who should and must enter care, what type of care and how long for, how people were to be treated in care, and how and to what extent abusers and those who contributed to abuse and neglect in care would be held to account.

506. The State failed to uphold all of its responsibilities for the care system, which contributed to abuse and neglect. This section sets out the following failures:

• the State did not give effect to te Tiriti o Waitangi or fulfil its human rights obligations
• legislative and policy settings were discriminatory and ignored people’s rights› this discriminatory approach reflected a lack of diverse leadership
• people in care had limited input into State decision-making
• the State’s attempts to address institutional discrimination fell short
• the State did not ensure that people in care were safeguarded from abuse and neglect
• the State lost sight of its core regulatory, enforcement and funding functions
• the State’s highest-level decision-makers rarely took accountability for abuse and neglect in their care.

507. During the Inquiry period, the rights guaranteed to Māori in te Tiriti o Waitangi were largely absent in care settings. The care systems into which Māori were taken and placed during the Inquiry period were generally a “Pākehā-centric one-size-fits-all” approach that was culturally inappropriate for Māori. Māori thinking, approaches and values were not incorporated into the care systems for tamariki, rangatahi and pakeke in care. The lack of kaupapa Māori options as part of the care systems breached te Tiriti o Waitangi principles of options, partnership, active  protection, and equity.

508. Similarly, human rights protections were largely absent from care settings for most of the Inquiry period. Many children, young people and adults in State and faith-based care were isolated from their whānau, kāinga and communities.

509. Inadequate standards of care, failure to implement existing standards, and breaches of standards contributed to different forms of serious abuse and neglect across all care settings. People in care were regularly dehumanised and denied human dignity. These failures resulted in inappropriate and unsafe care placements, and a one-sizefits-all regimented approach to care.

510. Throughout the Inquiry period, government agencies held multiple and conflicting roles in care. Agencies often designed their own standards and policies, regulated some care providers, owned and operated care facilities, delivered care, employed staff, oversaw and monitored their own services, and advised the State on care-related policies and regulation of the care system.

511. This concentration of power, where an agency could be responsible for all aspects of a situation from decision-making to service provision to monitoring, decreased accountability and increased the risk of abuse. Many staff and carers in government agencies were under-resourced, or had too many duties, leading to some of them having to ‘cut corners’ or not being able to carry out some of their duties.

512. Where there were complaints processes in place, these were ineffective and easily undermined. People in care faced barriers to making complaints and were often not believed and called liars or troublemakers if they did raise concerns. When there were concerns or complaints about abuse, it was often treated as an employment issue or as a sin to be forgiven, rather than as criminal behaviour that needed to be investigated and the perpetrator held to account. Senior leaders or managers often prioritised institutional reputations, and abusers’ reputations and future careers over the safety of people in their care. Abusers were often shifted to other residences or institutions.

513. Unlawful and serious breaches of standards of care were rarely reported to NZ Police. Senior leaders and managers often failed to report abuse or neglect to NZ Police. In some cases, they took deliberate steps to defer or avoid reporting and following through with other accountability steps, such as dismissal under employment laws. Other measures taken by senior leaders and managers included denying the abuse happened, blaming complainants for the abuse, taking a litigious response to complaints, or entering confidential settlements with abusers.

Faith-specific factors contributed to abuse and neglect in care

514. Part 7 of the Inquiry’s final report, Whanaketia – Through pain and trauma, from darkness to light, describes the faith-specific factors that contributed to the abuse and neglect of children, young people and adults during the Inquiry period in faith-based care. These factors included:

• the misuse of religious power
• the moral authority and status of faith leaders and the access this power, authority and status gave them
• gendered roles and sexism in positions of authority
• negative attitudes about sex and repression of sexuality
• racism and ableism based on religious concepts
• the interpretation of sexual abuse through the lens of sin and forgiveness
• harmful use of religious beliefs and practices.

515. Most of these factors did not have a significantly different effect on tamariki, rangatahi and pakeke Māori in care. The section below summarises how the racism and discrimination contributed to abuse and neglect of Māori survivors in faith-based care.

Racism and discrimination against Māori

516. Members of the Gloriavale Christian Community, including those of Māori descent, were told that te reo Māori was “Satan’s language” and people in the community were taught that Māori were lazy and thieves.[471] One survivor described how her school education on the colonisation of Aotearoa New Zealand was “factually inaccurate and dangerously incompetent” and Māori were described as “heathens and savages”.[472] Māori survivors at Gloriavale have told the inquiry about racial discrimination[473] and feeling a lot of shame about being Māori.[474]

517. The Gloriavale leadership taught members that “you don’t have ethnicity, you’re just a child of God”.[475] This erasure of Māori identity was reinforced by the education curriculum at Gloriavale. A document titled Gloriavale Christian School Quality Management System, which was prepared as recently as 2021, rejected Māori culture as “un-Christian”:

“We have our own unique Christian culture based on the teachings of the New Testament. Although we all have European or Māori ancestry or both, we do not think of ourselves as Europeans or Māori, rather we reject both these cultures as un-Christian since both are based on paganism and self-indulgence with a few perverted versions of biblical ideas mixed in. We accept no denominational labels but we are simply Christians. We do not keep non-biblical traditions amongst ourselves, whether of Māori or European origin. For example, we do not keep Christmas or Easter, or use pagan names for the days of the weeks or the months of the year. Nor do we seek to keep the Māori culture alive amongst ourselves. This is not from any racist motivation whatsoever, but as the scripture says, ‘There is neither Jew nor Greek, there is neither bond nor free, there is  neither male nor female for ye are all one in Christ Jesus’”.[476]

518. Rachel Stedfast, acting Principal of the Gloriavale Christian Community School, accepted in the Inquiry’s Faith-based Institutional Response Hearing that there has not been a strong focus on Māori culture at all at Gloriavale, and that there are parents who are opposed to it being taught.[477]

519. Some survivors of the Plymouth Brethren Christian Church described how the church leadership, and the church culture generally, were racist towards and dismissive of Māori.[478] The membership of the church is generally ethnically Pākehā, and one survivor said he was surprised to learn that there were a “smattering” of Māori members.[479]The Plymouth Brethren Christian Church told the Inquiry they see people as equal, regardless of their ethnicity.

520. The Plymouth Brethren Christian Church told the Inquiry that as a faith-based organisation they do not have any formal obligations under te Tiriti o Waitangi and that Māori have the same rights as everyone else.[480] Despite this, a former member said:

“[Plymouth Brethren] are genetically Anglo-European, as a direct consequence of their religious-social exclusion of all others … Māori world view, values, concerns, and histories are roundly dismissed. Māori are denigrated along with the denigration of all ‘worldly’, non-[Plymouth Brethren] cultures. [Plymouth Brethren] children absorb these attitudes as a matter of course.”[481]

Te Tiriti o Waitangi was largely absent in faith-based institutions

521. Although faith-based institutions are not te Tiriti o Waitangi partners themselves:

• legislation may require them to act consistently with te Tiriti o Waitangi[482]
• te Tiriti o Waitangi is relevant to interpreting legislation (or can be read into legislation) even where the legislation is silent on te Tiriti o Waitangi.[483] Therefore, te Tiriti o Waitangi may impact faith-based institutions when they care for tamariki, rangatahi and pakeke Māori, as te Tiriti o Waitangi is relevant to the care of tamariki and rangatahi Māori and it colours all legislation dealing with the status, future and control of tamariki.[484]
• if faith-based institutions made their own commitments to te Tiriti o Waitangi (for example, in governing documents or public statements) they may be accountable to meet those commitments.[485]

522. How te Tiriti o Waitangi applies in a given context depends on the particular circumstances.[486] In the absence of clear legislative direction, the faiths have taken varied approaches to consideration and implementation of the rights guaranteed in te Tiriti o Waitangi. Most faiths the Inquiry investigated started to make their own commitments to te Tiriti o Waitangi towards the end of the Inquiry period. For example, in 1989 at the Catholic Bishops Conference, te Tiriti o Waitangi was described as a sacred covenant, and in 1995 they went further acknowledging the
particular rights of Māori as the indigenous people.

523. The Anglican Church in Aotearoa, New Zealand and Polynesia has been constitutionally divided into three Tikanga: Tikanga Māori, Tikanga Pasifika and Tikanga Pākehā. Three Archbishops, one from each, form the ‘Primacy’ of the Anglican Church, or in other words, lead the church.[487] Although the three branches appear to be equal in terms of formal political authority, Tikanga Pākehā controls the bulk of resources. For every $1 of assets held by Tikanga Māori, Tikanga Pākehā holds $28 worth of assets.[488]Reverend Dinah Lambert, Chaplain of Te Aute College in Te Mataua-Māui Hawkes Bay, told the Inquiry that, in describing the sharing of resources with the Tikanga Māori arm of the church, Archbishop Brown Turei had said to her:

“sometimes, Dinah, it’s like you’re given a kete but it’s empty.”[489]

524. At the other end of the spectrum, Gloriavale and Plymouth Brethren Christian Church did not make any commitments to te Tiriti o Waitangi during the Inquiry period. Plymouth Brethren told the Inquiry that as a faith-based organisation they do not have any formal obligations under te Tiriti o Waitangi and that Māori have the same rights as everyone else.[490]

Societal factors contributed to abuse and neglect in care

525. Societal factors can have a significant impact on enabling or preventing abuse. Much of the abuse and neglect experienced by survivors was shaped by entrenched attitudes and systems of power and prejudice within society. These then shaped the different care systems.

526. During the Inquiry period, people in care were often seen as not normal or otherwise undesirable or flawed.[491] Delinquent, defective or deviant were common words used to refer to people in care.[492]Research shows that “children in residential care also lack value and worth in the eyes of the wider community; they are easily stereotyped and this affects the resources and investment made available for their care”.[493]
Social attitudes towards class, race, gender and disability inform and intensify this pattern.[494]

Racism persisted throughout the Inquiry period

527. The Inquiry heard how institutional, cultural and personal racism directly contributed to tamariki, rangatahi and pakeke Māori entering care and suffering abuse and neglect in care.

528. Institutional racism reflects broader racism present within Aotearoa New Zealand society. At the Inquiry’s State Institutional Response Hearing, the Chief Executive of Oranga Tamariki Chappie Te Kani acknowledged:

“The structural racism that exists in the care and protection system reflects broader society.”[495]

529. Institutional and structural racism was present in the care system throughout the Inquiry period.[496] It was rooted in the belief “that Pakeha culture, lifestyle and values are superior to those of other New Zealand cultures, notably those of Māori and Polynesian people.”[497] The 1988 Pūao-te-āta-tū report commented on the impact of institutional racism within the care system on Māori, noting:

“[t]he history of New Zealand since colonisation has been the history of institutional decisions being made for, rather than by, Māori people.”[498]

530. Throughout the Inquiry period this could be seen in “the prevailing deficit views of Māori as lazy, dependents of the state, incapable of providing the right family environment for their children”.[499]

Other discriminatory societal attitudes directly contributed to abuse and neglect in care

531. The Inquiry heard that other discriminatory societal attitudes – including ableism, disablism, audism, sexism, misogyny, homophobia, transphobia, negative attitudes towards children and young people, and discrimination against people experiencing poverty – contributed to abuse and neglect in State and faith-based care.

532. Ableism underpinned the views about disability and disabled people throughout the Inquiry period, and disablism was inherent within all care settings.[500] At the Inquiry’s State Institutional Response Hearing, the Director-General of Health Dr Diana Sarfati acknowledged “that institutional and societal ableism in legislation, policy and systems has contributed to the abuse of disabled people and people with mental health conditions in health and disability care settings.”[501]Tāngata whaikaha and tāngata whaiora suffered racism in combination with ableism and disablism, which heightened their risk of abuse and neglect in care.

533. Audism and a preference for oral communication directly contributed to Deaf people entering care and suffering abuse and neglect in care. This is discussed in detail in the Inquiry's case study on abuse and neglect at Van Asch College and Kelston School for the Deaf, Our Hands Were Tied. Tāngata Turi experienced the compounding effects of racism on top of audism in these care settings.

534. During the Inquiry period, women and girls were considered less valuable than men and boys and experienced gender-based discrimination. Sexist and misogynistic attitudes perceived women and girls as promiscuous, sinful and ‘dirty’ if they failed to adhere to strict social norms and gender roles. Wāhine Māori experienced sexist discrimination in combination with racism, which framed them as lazy, unintelligent and hyper-sexual. This view is evident in a 1965 letter from the Whangārei District Child Welfare Officer about admissions of girls to Fareham House in Pae-Tū-Mokai Featherston or Kingslea Girls’ Home in Ōtautahi Christchurch:

“The girls whom I refer are, in the main, the dull backward, affection starved Māori girls who cannot produce anything near a reasonable day’s work and who try and get their needed affection from any male who is handy.”[502]

535. Takatāpui, Rainbow and MVPFAFF+ people were perceived as deviant, sinful and needing to be ‘fixed’ during most of the Inquiry period. The Inquiry saw evidence of strongly homophobic attitudes in both State and faith-based care. People in care who were perceived or labelled as homosexual or did not adhere to socially accepted ‘masculine’ or ‘feminine’ behaviour were targeted. Diverse gender expression was also (wrongly) assumed to be related to sexuality. Takatāpui survivors experienced the compounding effects of racism as well as homophobia and transphobia.

536. Children and young people throughout the Inquiry period were often viewed as delinquent, troublemakers, inferior and flawed, and deserving of punishment.[503] These punitive societal attitudes directly contributed to children and young people entering care and suffering abuse and neglect in care.

537. Throughout the Inquiry period there were negative stereotypes about poverty and welfare. Poverty was seen as a problem with individuals rather than an outcome of wider social, economic and political circumstances.[504]

538. For tāngata whaikaha, tāngata whaiora, whānau hauā, tāngata Turi, wāhine Māori, Takatāpui, tamariki and rangatahi Māori, and Māori experiencing poverty, these discriminatory beliefs and negative societal attitudes were exacerbated by Aotearoa New Zealand’s entrenched societal, institutional and structural racism against Māori. This increased their risk of being placed into care, and suffering abuse and neglect in care.

Lessons identified and changes made during the Inquiry period

539. During the Inquiry period, the State and faith-based institutions made changes to prevent and respond to abuse and neglect, included the creation of new legislation, policy, rules, standards and practices, 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.

540. Key changes made that affected tamariki, rangatahi and pakeke Māori are summarised below.

541. During the Inquiry period, the State knew that Māori were the majority of people in social welfare care settings, and disproportionately represented across other care settings, but generally did not make changes to respond to this until the late 1980sand the 1990s.[505] There were several attempts to address over-representation of Māori through changes to policy and legislation, including with the recognition of whānau, hapū and iwi in the Children, Young Persons, and Their Families Act 1989.

542. In youth justice settings, Māori rangatahi continued to come to the attention of the State at a much higher rate than non-Māori and faced custodial sentences at a much higher rate than non-Māori.[506] The State’s ineffective approach to youth justice throughout the Inquiry period, as well as its failure to adequately address structural racism within the criminal justice sector, further compounded the negative impacts on Māori.

543. 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 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.

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

Footnotes

[458]Australian Institute of Family Studies, Risk and Protective Factors for Child Abuse and Neglect, (May 2017, pages 3, 7–8); Royal Commission into Institutional Responses to Child Sexual Abuse (Australia), Final report: Volume 2 – Nature and cause (2017, page 18).[459]Australian Institute of Family Studies, Risk and Protective Factors for Child Abuse and Neglect, (May 2017, pages 3, 7–8); Royal
Commission into Institutional Responses to Child Sexual Abuse (Australia), Final report: Volume 2 – Nature and cause (2017, page 18).
[460]Royal Commission into Institutional Responses to Child Sexual Abuse (Australia), Final report: Volume 2 – Nature and cause (2017, page 18).
[461]Waitangi Tribunal, He Pāharakeke, He Rito Whakakīkinga Whāruarua: Oranga Tamariki Urgent Inquiry (2021, pages 11–16).
[462]Waitangi Tribunal, He Pāharakeke, He Rito Whakakīkinga Whāruarua: Oranga Tamariki Urgent Inquiry (2021, page 100–101).
[463]Waitangi Tribunal, Tino Rangatiratanga me te Kāwanatanga: Te Paparahi o Te Raki Inquiry Stage 2 Report Part I (2023, page 69).
[464]State Services Commission, Public Service in a Multicultural Society: Waahi conference 1982 (1983, page 14).
[465]Waitangi Tribunal, Tino Rangatiratanga me te Kāwanatanga: Te Paparahi o Te Raki Inquiry Stage 2 Report Part I (2023, page 69).
[466]Treaty of Waitangi Act 1975, section 6(1).
[467]Māori Land Court, He pou herenga tangata, he pou herenga whenua, he pou whare kōrero: 150 years of the Māori Land Court (Māori Land
Court 2015, page 84).
[468] See Children, Young Persons, and Their Families Act 1989, sections 20–38; Mental Health (Compulsory Treatment and Assessment) Act
1992, section 7A.
[469]Waitangi Tribunal, He Pāharakeke, He Rito Whakakīkīnga Whāruarua: Oranga Tamariki Urgent Inquiry (2021, page 95).
[470]Waitangi Tribunal, He Pāharakeke, He Rito Whakakīkīnga Whāruarua: Oranga Tamariki Urgent Inquiry (2021, page 179).
[471]Witness statement of Ms KM (10 June 2021, page 5).
[472]Witness statement of Ms PQ (June 2021, para 3.5.16)
[473]Witness statement of Ms KY (2 June 2021, page 4).
[474]Witness statement of Ms KM (10 June 2021, page 5).
[475]Private session transcript of survivor who wishes to remain anonymous (page 35).
[476]Transcript of evidence of Howard Temple and Rachel Stedfast on behalf of Gloriavale Christian Community at the Inquiry’s Faith-based Institutional Response Hearing (Royal Commission of Inquiry into Abuse in Care, 13 October 2022, page 84).
[477] Transcript of evidence of Howard Temple and Rachel Stedfast on behalf of Gloriavale Christian Community at the Inquiry’s Faith-based Institutional Response Hearing (Royal Commission of Inquiry into Abuse in Care, 13 October 2022, page 85).
[478] Submission to the Royal Commission of Inquiry into Abuse in Care of Craig Hoyle (14 July 2022, page 12); Witness statement of Mr UJ (7 July 2022, page 4).
[479]Submission to the Royal Commission of Inquiry into Abuse in Care of Craig Hoyle (14 July 2022, page 12).
[480]Royal Commission of Inquiry into Abuse in Care, Internal notes from the Inquiry’s meeting with representatives of the Plymouth Brethren Christian Church (29 November 2022, page 24).
[481]Witness statement of Mr UJ (7 July 2022, paras 3.12–3.13).
[482]Education and Training Act 2020, sections 4, 5, 9 and 127.
[483]See Trans-Tasman Resources Ltd v Taranaki-Whanganui Conservation Board [2021] 1 NZLR 801, [2021] NZSC 127 (paras 8 and 151); Ngāti Whātua Ōrākei Trust v Attorney-General [2022] NZHC 843 (para 589); and Huakina Development Trust v Waikato Valley Authority [1987] 2 NZLR 188 (HC).
[484]Barton-Prescott v Director-General of Social Welfare [1997] 3 NZLR 179 (para 184).
[485]See Te Pou Matakana Limited v Attorney-General [2022] 2 NZLR 148, [2021] NZHC 2942. Although this case concerned the Ministry of Health’s policy commitments to exercise its powers in accordance with te Tiriti o Waitangi, it may be arguable that faith-based institutions exercise public powers and functions when providing care.
[486]New Zealand Maori Council v Attorney-General [1994] 1 NZLR 513 (PC) at 517 (the Broadcasting Assets case); and Ngāti Whātua Ōrākei Trust v Attorney-General [2022] NZHC 843 at [593] and [596].
[487]Royal Commission of Inquiry into Abuse in Care, He Purapura Ora, he Māra Tipu: From Redress to Puretumu Torowhānui Volume 1 (2021, page 183).
[488]He waka eke noa – A waka we are all in together (Anglican Church, 2020, page 22).
[489]Transcript of evidence of Reverend Dinah Lambert at the Inquiry’s Tō muri te pō roa, tērā a Pokopoko Whiti-te-rā (Māori Experiences) Hearing (Royal Commission of Inquiry into Abuse in Care, 15 March 2022, page 483).
[490]Royal Commission of Inquiry into Abuse in Care, Internal notes from the Inquiry’s meeting with representatives of the Plymouth Brethren Christian Church (29 November 2022, page 24–25).
[491]Expert Brief of Dr Patsie Frawley (April 2022, page 3).
[492]Witness statements of Ms EJ (13 May 2022, para 95) and Ms QK (22 November 2022, para 30); Letter from Ann Hercus, the Minister Social Welfare to Dr Oliver Sutherland, Auckland Committee on Racism and Discrimination, regarding a 10 year old State ward held in secure at Owairaka (15 March to 20 June 1985, pages 2–3); Paul, DB, Stenhouse, J, & Spencer, HG (eds) Eugenics at the Edges of Empire: New Zealand, Australia, Canada and South Africa (Springer, 2017, page 25); Statement of Dr Hilary Stace for the Contextual Hearing (October 2019, para 5).
[493]Colton, M, “Factors associated with abuse in residential child care institutions.” Children & Society 16(1) (2002, page 37).
[494]Colton, M, “Factors associated with abuse in residential child care institutions.” Children & Society 16(1), (2002, page 37); Mirfin-Veitch, B, Tiako, K, Asaka, U, Tuisaula, E, Stace, H, Watene, F.R, & Frawley, P, Tell me about you: A life story approach to understanding disabled people’s experiences in care 1950-1999 (Donald Beasley Institute, 2022, pages 117–118).
[495]Transcript of evidence of Chappie Te Kani, Chief Executive of Oranga Tamariki, at the Inquiry’s State Institutional Response Hearing (Royal Commission of Inquiry into Abuse in Care, 22 August 2022, pages 576—577)
[496]Transcript of evidence of Chappie Te Kani, Chief Executive of Oranga Tamariki, at the Inquiry’s State Institutional Response Hearing (Royal Commission of Inquiry into Abuse in Care, 22 August 2022, pages 576–577; Brief of Evidence of Dr Diana Sarfati on behalf of the Ministry of Health for the Inquiry’s State Institutional Response Hearing (Royal Commission of Inquiry into Abuse in Care, 17 August 2022, para 2.8(4)).
[497]Māori Perspective Advisory Committee, Puao-te-ata-tu (day break): The report of the Ministerial Advisory Committee on a Māori perspective for the Department of Social Welfare (Department of Social Welfare, 1988, page 77).
[498]Māori Perspective Advisory Committee, Puao-te-ata-tu (day break): The report of the Ministerial Advisory Committee on a Māori perspective for the Department of Social Welfare (Department of Social Welfare, 1988, page 18).
[499]Stanley, E, The road to hell: State violence against children in postwar New Zealand (Auckland University Press, 2016), as cited in Savage, C, Moyle, P, Kus-Harbord, L, Ahuriri-Driscoll, A, Hynds, A, Paipa, K, Leonard, G, Maraki, J, & Leonard, J, Hāhā-uri hāhā-tea: Māori involvement in State care 1950–1999 (Ihi Research, 2021, page 55).
[500]Brief of evidence of Dr Brigit Mirfin-Veitch for the Inquiry’s Ūhia te Māramatanga Disability, Deaf and Mental Health Institutional Care Hearing (Royal Commission of Inquiry into Abuse in Care, June 2022, para 73).
[501]Brief of evidence of Dr Diana Sarfati on behalf of the Ministry of Health for the Inquiry’s State Institutional Response Hearing (Royal Commission of Inquiry into Abuse in Care, 17 August 2022, para 2.8(5)).
[502]Letter from LM Uttley, District Child Welfare Officer, to the Superintendent of Child Welfare, Re: Admissions to training centres (24 May
1965, page 1).
[503]Maxwell, G, Youth offenders: Treatment of young offenders, 1840 to 1980s (Te Ara – the Encyclopedia of New Zealand, 2011, pages 1–2).
[504]Hackell, M, “Managing anxiety: Neoliberal modes of citizen subjectivity, fantasy and child abuse in New Zealand” in Citizenship Studies Volume 20, Nos 6-7 (2016, pages 867–870)
[505]Savage, C, Moyle, P, Kus-Harbord, L, Ahuriri-Driscoll, A, Hynds, A, Paipa, K, Leonard, G, Maraki, J, & Leonard, J, Hāhā-uri hāhātea: Māori involvement in State care 1950–1999 (Ihi Research, 2021, pages 13, 16, 61, 109, 139).
[506]Watt, E, A history of Youth Justice in New Zealand: Research paper commissioned by the Principal Youth Court Judge Andrew Becroft (2003, pages 13–16); Savage, C, Moyle, P, Kus-Harbord, L, Ahuriri-Driscoll, A, Hynds, A, Paipa, K, Leonard, G, Maraki, J, & Leonard, J, Hāhā-uri hāhā-tea: Māori involvement in State care 1950–1999 (Ihi Research, 2021, pages 136–138)