128. 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.

129. The Inquiry identified that four factors all caused or contributed to the abuse and neglect of Pacific survivors 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.

130. This chapter sets out the factors that did have particular effects for Pacific Peoples and explains the reasons for this.

The people at the centre of abuse and neglect

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

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

133. Pacific children, young people and adults 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.

134. 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.

135. Had these rights been upheld during the Inquiry period – such as the right to tino rangatiratanga over kainga, 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.

136. 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.

137. Many of the personal circumstances that made it more likely a child, young person or adult would enter care were also often factors that 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 racism, ableism, disablism, sexism, homophobia and transphobia, and negative stereotypes about children and young people, poverty and welfare dependency

138. 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.

139. Most survivors of abuse and neglect in State and faith-based care had or experienced many of these factors, which heightened their risk of abuse and neglect. For Pacific Peoples in care, this meant that they were more susceptible to abuse and neglect if they were also raised in poverty, were Māori, Deaf, disabled, or experienced mental distress, were Takatāpui, Rainbow, MVPFAFF+, or had multiple combinations of these circumstances.

140. Part 3 of the Inquiry’s final report, Whanaketia – Through pain and trauma, from darkness to light, explained that racism and other discriminatory attitudes towards migrants contributed to Pacific children and young people being targeted by NZ Police and other State agencies, particularly during the 1950s–1970s. Pacific parents were often only able to get low-paying, labour-intensive jobs with long hours, meaning children were sometimes left to look after themselves or younger siblings. Some Pacific survivors experienced physical, psychological and sexual abuse and neglect at home. Children and young people often ‘acted out’ in response to stressors at home or school. Personal circumstances such as these contributed to disproportionate numbers of Pacific children and young people entering social welfare care. These same personal circumstances made Pacific people more susceptible to experiencing abuse and neglect while in care.

141. A key factor that contributed to abuse and neglect in care were abusers. 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.

142. 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.

143. The Inquiry heard about the importance of the Pacific values fa’aaloalo (respect) and tapuakiga/talitonuga (spirituality, indigenous beliefs and Christianity). Christian missionaries have had a significant and far-reaching impact on Pacific communities, who have incorporated Christianity into their own belief systems.[133] Many Pacific Peoples consequently have a deferential attitude to people in positions of authority, especially people in religious ministry.

144. At the Inquiry’s Faith-based Institutional Response Hearing, the Bishop of Auckland, Bishop Steve Lowe, acknowledged that the way that priests are highly regarded by not just Pacific communities but other cultures as well within the Catholic Church has sometimes been damaging and needs to change.[134]

145. For many Pacific survivors and their families, obedience to religious authority was so ingrained they complied with the orders of clergy or other religious leaders. This made barriers to reporting particularly strong.[135] Many survivors, including Samoan and Māori (Ngāti Kahungunu, Te Aitanga ā Mahaki, Ngāti Māroko) survivor Rūpene Amato, told the Inquiry that at the time they felt the people they might have disclosed to, including their own families, would not believe that a person with religious status could commit abuse.[136]

146. Some Pacific kainga faced pressure to put their family members into State-run disability care facilities and were not offered resources, information or education about disability to support informed placement decisions.[137] In addition, Pacific kainga – many of whom hold respect for authority as a central cultural value – felt that questioning the advice and diagnoses of medical professionals was sometimes difficult.[138] For example, Samoan survivor Lusi Faiva told the Inquiry:

“I was two years old when I was diagnosed with cerebral palsy. There was little support for disabled children and their families when I was little. The doctor instructed my mum for me to go to an institution, he said, ‘it would be better this way’. Soon after I was moved to Kimberley centre.”[139]

Institutional and systemic factors that contributed to the abuse and neglect of Pacific survivors

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

• standards of care were inconsistent and routinely breached
• 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, kainga, communities and advocates
• there was little accountability for abuse and neglect.

148. The Inquiry examined the State’s responsibility for the abuse and neglect in care that occurred during the Inquiry period. The State was ultimately responsible for safeguarding all people in care, regardless of the care setting, and for 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.

149. During the Inquiry period, the rights guaranteed to Māori in te Tiriti o Waitangi were absent in care settings. 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, kainga and communities. This contributed to cultural abuse and racism for Pacific and Māori people in care.

150. 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-size-fits-all regimented approach to care.

151. 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.

152. 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.

153. 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 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.

154. 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 that contributed to the abuse and neglect of Pacific survivors

155. 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 in faith-based care during the Inquiry period. 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.

156. Negative attitudes about sex, and repression of sexuality, had particular effects for Pacific Peoples in faith-based care. Although attitudes towards sex outside of wedlock have shifted in Aotearoa New Zealand over the course of the 20th century, pregnancy outside of marriage is still associated with shame in some Pacific Island communities.[140]

157. Pacific survivors described a culture where discussion of sexual matters was repressed. Evidence shows that institutional cultures where discussing sex is taboo can elevate the risk of sexual abuse.[141] This elevated risk can be because adults and children may be unable to distinguish between appropriate and inappropriate interactions,[142] and it can also pose barriers to reporting sexual abuse.[143] At the Inquiry’s Faith-based Redress Hearing, Cardinal Dew, Catholic Archbishop of Wellington, said:

“It’s a very difficult topic I find with Pasifika families, because often sexuality is not mentioned or spoken about, and there’s the added complexity of the culture of the church where they don’t want to speak about anything to do with sexuality and they want to keep the church, and especially clergy, at a level that’s not real.”[144]

158. In some cases, this secrecy and taboo meant ‘sex education’ could become an excuse, a front, or an opportunity for abuse. Survivor Rūpene Amato, who attended St Joseph’s School (Catholic) in Wairoa, told the Inquiry that a priest used one-on-one meetings in his home under the guise of ‘sex education’ to sexually abuse him and many of his classmates.[145]

159. The Inquiry’s summary report on survivors’ experiences of abuse and neglect in faith-based care has more detail on the factors that that were specific to faith-based care settings.

Societal factors that contributed to abuse and neglect in care

160. The Inquiry heard how societal factors, such as racism, sexism, ableism, disablism, discrimination against Deaf people, homophobia and transphobia, and negative stereotypes about children and young people, poverty and welfare dependency, contributed to survivors entering State and faith-based care and suffering abuse and neglect in care.

161. These societal attitudes were upheld by staff within care settings, which in turn contributed to abuse and neglect. The Inquiry also saw evidence of racist attitudes towards Pacific children, young people and adults in care. These were often combined with negative and discriminatory attitudes about migrants, which were exacerbated during and after the Dawn Raids in the mid-1970s. The culture of most State and faith-based care settings mirrored an ignorance of Pacific cultures within wider Aotearoa New Zealand society and the official policy of ‘assimilating’ Pacific migrants.[146]

162. Many of the State’s discriminatory policies and practices contributed to high rates of entry into care and abuse, disproportionately impacting Pacific Peoples. Pacific people in care were separated from their aiga and kainga and experienced alienation from their cultures, languages and identities. Pacific Peoples were not able to access culturally appropriate forms of care for much of the Inquiry period.

163. Discriminatory legislation, policies and practices reflected the views and attitudes of the people who designed them.[147] By and large those people lacked diversity and lived experience.[148] Pacific survivors and their families’ perspectives and solutions were often marginalised, and excluded from influencing the design of legislation, policies and practices.

164. Institutional and structural racism was present in the care system throughout the Inquiry period.[149] 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.”[150] In the Inquiry’s State Institutional Response Hearing, the Crown acknowledged that institutional or structural racism and ableism in legislation, policy and systems contributed to the disproportionate representation of Pacific Peoples in care.[151]

165. At the Inquiry’s State Institutional Response Hearing, Chappie Te Kani, Chief Executive of Oranga Tamariki, acknowledged that structural racism exists in the care system, and that it is a reflection of broader societal attitudes within Aotearoa New Zealand.[152]

166. From the late 1980s onwards, the State did take some steps to address institutional discrimination, particularly racism, and how it contributed to disproportionate numbers of Māori and Pacific Peoples being in care settings. However, at the end of the Inquiry period, institutional discrimination persisted and continued to result in disproportionate numbers of Māori and Pacific Peoples entering care.

Lessons identified and changes made

167. 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.

168. 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.

169. 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.

170. 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.

Footnotes