210. 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. . In addition, Part 7 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.

211. The Inquiry identified that four factors all caused or contributed to the abuse and neglect of survivors in mental health settings. These included:

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

212. 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.

213. Many of the personal circumstances that made it more likely a child, young person or adult would enter care, often became the factors for why they were more susceptible to, or 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, transphobia and negative stereotypes about children and young people.

214. 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
• having 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.

215. 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 children, young people and adults in mental healthcare settings, this meant that they were more susceptible to abuse and neglect if they were raised in poverty, were Māori, Pacific, Deaf, disabled, Takatāpui, Rainbow, MVPFAFF+, or experienced mental distress, or multiple combinations of these circumstances.

216. 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.

217. The systemic or institutional factors that contributed to abuse and neglect in care during the Inquiry period, which are described in detail in Part 7 of the Inquiry’s final report, Whanaketia – Through pain and trauma, from darkness to light, 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.

218. All of the systemic or institutional factors that contributed to abuse and neglect were present in mental healthcare settings. Part 7 of the Inquiry’s final report, Whanaketia – Through pain and trauma, from darkness to light, describes these in detail. This chapter focuses on the factors that were particularly acute in mental healthcare settings.

219. The Inquiry examined the responsibility of the State and faith-based institutions in respect of the abuse and neglect in care that occurred during the Inquiry period. The failures of the State to uphold its responsibilities impacted children, young people and adults in care and are described in detail in Part 7 of the Inquiry’s final report, Whanaketia – Through pain and trauma, from darkness to light. This chapter focuses on the failures that were particularly acute in mental healthcare settings.

The people at the centre of abuse and neglect

220. 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.

221. 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.

222. 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

223. 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.

Abusers

224. Staff and caregivers in institutional and residential settings had almost total power and control over the lives of people in their care. Medical professionals and healthcare workers held positions that gave them coercive statutory powers to place people in care, at times without any consent, decide their treatment, including at times the use of compulsory orders, and decide what supports they could access. Some people misused the power and control that came with these positions to inflict certain types of abuse and neglect.

225. Abusers were rarely held to account for their abuse and neglect. Institutional and system failures made it easier for many abusers to conceal their actions, interfere with complaints processes and continue abusing often with a sense of impunity.

226. Some survivors were abused by others of a similar age, or those placed in the same setting, in what is known as ‘peer-on-peer’ abuse. In care settings, a culture of physical or sexual violence could be established through staff condoning or even encouraging peer-on-peer abuse between residents.

Bystanders

227. For some bystanders, the care environment was a significant factor in whether they would intervene when they saw signs of abuse or neglect:

“Quite aside from the issue of abusive people in positions of power within institutions, the institutionalisation of staff and residents led to an environment in which bad practices were not challenged.” [178]

228. Bystanders consistently failed to intervene to stop or report abuse and neglect because:

• the people in their care had become dehumanised in their eyes, so they no longer cared what happened to them
• they gave abusers “the benefit of the doubt” due to personal relationships, grooming, and cognitive bias
• they were reluctant to intervene due to fear of reprisals, or there was an institutional culture that discouraged or suppressed intervention
• they were not trained to identify signs of abuse or neglect
• they had become desensitised to abuse and neglect because it was commonplace and normalised in the care setting
• there was little consequence for not intervening or reporting (voluntary reporting was introduced in 1989 and reporting protocols for agencies and care providers in 1995).

Standards of care were routinely breached

229. Before and throughout the Inquiry period, mental healthcare settings had common legal standards to prevent ill-treatment, later called abuse and neglect. These common standards were all similar to this standard for institutional care which had been in place since 1911.

“Every Superintendent, licensee, officer, nurse, attendant, householder, or other person having the oversight, care, or control of any mentally defective person, or employed in any institution, house, or place in which any such mentally defective person resides, who strikes, wounds, or ill-treats, or wilfully neglects, any such mentally defective person is guilty of an indictable offence.”[179]

230. Before and throughout the Inquiry period, across all State and faith-based care settings it was a criminal offence to sexually abuse or indecently assault a person in care (consent was not a defence),[180] with special provisions for women and girls, regardless of age, in institutional care.

“Every person is guilty of an indictable offence who has or attempts to have carnal knowledge of any female who is detained under the provisions of the Act, or is otherwise under oversight, care, or control as mentally defective [consent is no defence].”[181]

231. Between 1950 to 1992, it was left to government agencies and institutions to decide whether and how they would protect the rights of the people in their care. From November 1992, the basic rights of people subject to compulsory mental health treatment orders were protected in legislation.[182] They had:

• the right to know their rights while in care and have a copy in writing:
• the right to an interpreter, including for te reo Māori or to meet their communication needs
• access to independent legal and psychiatric advice
• the right to company
• the right to send and receive mail and make phone calls.

232. A complaints process was also included which provided important protections including the requirement for directors of area mental healthcare services to rectify matters and rights of appeal.[183] There was also a general emphasis on family connections and cultural identity and connections to support protective factors while in care.

233. There was a legislated requirement in the Health and Disability Services Act 1993 for standards of services (rather than care or preventing and responding to abuse or neglect in the care of a provider), and general objectives to secure the best health, care and greatest independence for people receiving the services. The Department of Health’s 1992 Child Abuse Guidelines for Health Services set standards for preventing and responding to abuse.[184]

234. From 1996, most people in the care of health and disability service providers were also entitled to services that met the standards in the Code of Health and Disability Services Consumers’ Rights. There were limitations on the right to informed consent for some people who were considered unable to do so or where compulsory mental health treatment was ordered.[185] The standards in the code focused on the rights of people in care, including:

• the right to be treated with respect
• the right to be free from discrimination, coercion, harassment and exploitation
• the right to dignity and independence
• the right to make an informed choice and give informed consent (although people subject to a compulsory order were specifically excluded from this right).[186]

Individual care needs were often not recorded or were ignored

235. Some care settings had record keeping and data management policies regarding individual care needs in place,[187] however the Inquiry heard evidence that these policies were not always followed and did not require the ethnicity or cultural identity of people in care in care to be recorded. 

236. Several survivors told the Inquiry that their ethnicity was misidentified, incorrectly recorded or not recorded at all.[188] This primarily affected Māori and Pacific survivors. Research has found evidence of “insufficient, patchy and poor-quality ethnicity data collection across State care institutions”.[189]

237. From the late 1980s, failures to accurately identify and record individual care needs often meant services or funding were not provided to the person in care despite their care needs and eligibility.

238. In 1994, the State introduced the Needs Assessment and Service Coordination service. The purpose of this service was to identify the needs of disabled people and people experiencing mental distress and match these to standardised funding and services.[190] The foundational policy for the Needs Assessment and Service Coordination service identified that it should not treat disabled people as being sick, it should be culturally sensitive and be flexible and innovative.[191] However, during the Inquiry period the service was based on a medical approach to treating impairments rather than the holistic the needs of the person and their whānau.

239. While some people were provided with the right supports and care through the Needs Assessment Service Coordination service, some were not which increased their risk of abuse and neglect. Several reports were published in the late 1990s and early 2000s highlighting problems with the service, particularly for Māori and Pacific Peoples.[192] In 2003, the National Advisory Committee on Health and Disability would recommend the service be fundamentally redesigned because of its shortcomings in identifying and meeting the needs of disabled people and people experiencing mental distress.[193]

Institutional environments and practices that breached standards

240. During the Inquiry period, many children, young people and adults were placed in large-scale mental healthcare settings. Institutional models of care, which included institutional environments and practices, were a feature of these care settings.

241. Despite the diversity of people in settings and their different needs, they experienced a heavily regimented one-size-fits-all model of care with the same form of care applied to everyone regardless of their age, gender, abilities, culture, needs and reasons for being in care.

242. Conformity with rules and discipline and order were prioritised over the needs of people in care, described as an approach of “rules, power and control”.[194] Conformity was often enforced through harsh and abusive discipline.[195]

243. For some larger institutions, a strict one-size-fits-all routine meant they could rely on smaller staff numbers. The Inquiry heard that smaller staff numbers led to people in care losing their independence and individuality.[196]

244. An emphasis on conformity over individual needs resulted in standards of care being overlooked or ignored and people in care not receiving the level of care they needed, increasing the risk of abuse and neglect. For example, in its report to the Minister of Health in 1986, the Department of Health said:

“In most psychiatric hospitals in New Zealand the range of treatment options available is inadequate so that patients with very different needs are often treated in the same ward with the same programme … the lack of individualised assessment, treatment and rehabilitation programmes tends to lead to undue reliance on drug therapy and various forms of custodial care; and to seclusion.”[197]

245. In that same report, the Minister of Health was told there was a widespread lack of formal recognition of the cultural needs of people in mental health settings, such as access to te reo Māori interpreters, rongoā practitioners or cultural support groups.[198]

246. Overcrowding was common in mental health settings.[199] Many institutions had substandard physical environments. Buildings were outdated, poorly designed and inappropriate. Overcrowding often led to compromised daily routines like reduced or absent oversight, lack of individualised care and limited activities. Many people in overcrowded and unsuitable environments suffered abuse and neglect, including:

• sexual abuse
• a lack of privacy and dignity through open toilet, washing, and sleeping areas
• compromised personal hygiene and dental and medical care
• no access to clean personal items like clothes and shoes
• limited warm clothing and bedding
• generally unsanitary living conditions.[200]

247. Geographically isolated facilities could increase the risk of abuse and neglect by creating opportunities and cultures of total control with limited outside influence.[201] Isolated facilities could also lead to staff focusing on control and surveillance, which contributed to them becoming desensitised to the needs of people in their care.[202] Isolated areas within facilities could become areas where abusers would have unsupervised access to people in care and their abuse hidden from sight.[203] Isolated facilities could also make it difficult for families and whānau to connect with and visit their loved one in care, a critical protective and safeguarding factor.

248. Secure units were an unsuitable physical environment that contributed to the abuse and neglect of children, young people and adults in care.

Solitary confinement, seclusion and secure care wrongfully used as punishment

249. Some settings had standards that limited the use of solitary confinement, seclusion or secure care. For example, under the Mental Health (Compulsory Assessment and Treatment) Act 1992 it was only to be used if necessary, where necessary, and for as long as it was necessary, for the care or treatment of the patient or the protection of other patients.[204]

250. Despite these limits on the use of solitary confinement, seclusion and secure care, the Inquiry found survivors commonly reported the wrongful use of solitary confinement in mental health facilities.

Medical standards were frequently breached, at times unlawfully

251. Despite a range of medical standards being in place, the Inquiry found some children, young people and adults in care experienced over-medicalisation, lobotomies, sterilisation, invasive genital examinations, experimental psychiatric treatments without informed consent, electric shocks and injections of paraldehyde as punishment, which exposed some patients to unreasonable medical risks.

252. Many people in care were medicated for long periods without the necessary medical reviews:[205]

“Significant numbers of patients continue to be given drugs for lengthy periods without review. Such lack of review of individual treatments is of particular concern as many of the drugs, if given over prolonged periods, are capable of producing serious side effects.”[206]

Poor employment policies, practices contributed to abuse, neglect

253. Many staff and carers in mental health settings genuinely approached their position to do the best they could for those in their care. However, poor employment policies combined with poor senior leadership and management practices could undermine or make it harder for individual staff and carers to safeguard people in care.[207]

254. Generally, employment policies and practices were left to each setting to decide what was needed from 1950 through to the late 1980s. Some departments would set broad, process-based requirements through service contracts.[208] From the late 1980s, different settings had different legal obligations.

255. During the Inquiry period there were no mandatory vetting requirements or policies for mental health settings. At times there was a deference to membership of professional bodies like the New Zealand Medical Council, the regulatory body for doctors.

256. The Medical Council could not register people who had been convicted of any offence punishable by imprisonment of two years or more or who were “otherwise not of good fame or character”.[209]

257. The Medical Practitioners Act 1995 tightened restrictions on registration. Doctors who had been convicted of any offence punishable by imprisonment for a term of three months or longer had to satisfy the Medical Council that the offence would “not reflect adversely on his or her fitness to practice medicine”.[210] The Medical Council could also decline registration if an individual was “not fit to practice medicine by reason of any mental or physical condition”,[211] if they had been the subject of professional disciplinary proceedings,[211] or were otherwise “not fit to practice medicine”.[213]

258. However, as the Medical Council acknowledged at the Inquiry’s Lake Alice Child and Adolescent Unit Hearing in June 2021, it did not always act to ensure that people in care were safe from doctors who should not have been practicing.[214]

259. The Nursing Council of New Zealand decided who could become a registered nurse. Throughout most of the Inquiry period the only restrictions outlined in the governing legislation were that the nurse had to be a certain age and “of good character and reputation”.[215]

Staff and carers were often compromised by under resourcing

260. Understaffing in mental health settings contributed to abuse and neglect in care through staff being overworked, tired and under pressure. This affected their ability to provide individualised care, and contributed to emotional, physical, and educational neglect of people in care. It also contributed to abuse and neglect through inadequate oversight or supervision of staff which provided abusers with opportunities to abuse or neglect people in their care.[216]

261. Understaffing in mental health settings was a common problem.[217] Many staff said they felt overworked, under pressure and tired due to understaffing.[218] A 1986 review of psychiatric and psychopaedic hospitals made a direct link between understaffing and neglect of patients, noting that insufficient staff numbers led to “deficiencies in dignity and in the basic elements of appropriate care”.[219] The review also found that:

“Staff shortages and low morale seriously affect patient care and … lead to lack of awareness and general acceptance of substandard conditions ... staff often appear defeated and convey an air of resignation.”[220]

262. Some staff from mental healthcare settings told the Confidential Forum for former in-patients of psychiatric hospitals about having “a lack of time for kindness”.[221] The 1996 second Mason inquiry into mental healthcare services found that “multi-disciplinary staff shortages have resulted in lower standards of care.”[222]

263. Throughout the Inquiry period care work was not valued by society. This inadequate recognition contributed to conditions where staff and care workers were not appropriate or appropriately trained, were underpaid, experienced poor working conditions, and were otherwise not supported to provide safe and therapeutic care. These factors contributed to environments in which abuse was more likely to occur.

264. Poor supervision or performance management contributed to abuse and neglect because it became accepted and staff and carers were not held to account for abuse or neglect.

“A culture of using physical violence against children, young people and adults in care was so normalised in some care settings that staff found it difficult to intervene when they witnessed abuse or were ostracised if they complained.”[223]

Inadequate training and development to deliver care

265. Many staff and carers did not have the training and development needed for their roles and the demands they faced in care settings, particularly in overcrowded and under-resourced facilities. For regulated care professions like medical professionals, training, development and vetting could form part of their registration requirements.

266. In mental healthcare settings there were numerous reports of a lack of training of both clinical and non-clinical staff and concerns about how that affected children, young people and adults in care.[224] The second Mason inquiry into mental health services in 1996 found a lack of trained staff, particularly in child and adolescent mental health.[225] Where training was provided, it sometimes taught techniques that were not appropriate for a supportive care environment.[226]  

267. Referring to the recommendations on patient rights in the 1983 Gallen Inquiry, the Mason Inquiry said the changes in the Mental Health (Compulsory Assessment and Treatment) Act 1992 that provided better protection for patients, and should have reduced inpatient admissions, required significant staff training and resourcing to be effective. That training and resourcing had not happened. The necessary community-based services had not been set up and as a result hospital admissions were still seen as the mainstay of crisis response.[227]

268. Before the 1980s, there was limited training and development of staff and care workers to identify signs of abuse and neglect in care.[228] From the 1980s onwards, most care settings began developing their own guidance and training, initially focusing on sexual abuse.

269. The Department of Health issued Child Abuse Guidelines for Health Services in 1992 to supplement area health boards’ own policies and processes on identifying and responding to signs of abuse and neglect:

“The safety of the child is paramount. Health service providers must therefore ensure that staff are provided with a basic knowledge and understanding of the indicators of child abuse, and the appropriate reporting procedures to follow.”[229]

Few records were kept of complaints of abuse and neglect

270. Although mental healthcare settings were subject to the record keeping requirements of the Archives Act 1957 (detailed in Part 2 of the Inquiry’s final report, Whanaketia – Through pain and trauma, from darkness to light), few records were kept of complaints of abuse and neglect in mental healthcare settings. Before 1992, complaints were routinely not recorded in mental healthcare settings. When recorded, they were often not reflective of what had happened, and were dismissive of the abuse and/or neglect reported. There are limited records regarding complaints made to relevant professional bodies.[230]

271. The 1983 Gallen Inquiry found that incidents and allegations of ill treatment at Oakley Hospital in Tāmaki Makaurau Auckland were not recorded on patient files. Instead, an incident book was used to record altercations on the ward, including between patients and staff. The Gallen Inquiry indicated that this was done out of a desire to protect staff from any disciplinary action that might result from an allegation of mistreatment.[231]

272. The Gallen Inquiry noted that the proper process was for complaints and violent incidents to be recorded on patient files and properly investigated, including referring matters to the official visitor as soon as possible after they occurred.[232]

273. There was also a failure to report complaints to the appropriate authorities. The Inquiry heard evidence that across multiple institutions there was a reluctance by staff to involve NZ Police in complaints of abuse and neglect.

274. Pākehā survivor Alison Pascoe (deceased), who was in Kingseat Psychiatric Hospital in Karaka, reported that she was sexually assaulted by a male patient when she was 12 years old, around 1954. After she disclosed the incident to staff, there were some repercussions for the patient, but there was no police involvement. Alison told the Inquiry that staff:

“…should have called the Police. I don’t know why they didn’t. Patients had no rights.”[233]

Complaints processes were absent or easily undermined

275. Until the 1990s, the primary mechanism for people in care to raise concerns or make complaints was through district inspectors and official visitors. Unlike district inspectors, official visitors did not need to be highly qualified but have “impartiality, respectability and social concern”.[234]

276. In the early years, there were too few district inspectors, only two in the whole country in the 1960s, increasing to 27 by 1997.[235] Their role was poorly defined, and many patients were not aware of them or how to speak to them. While the official visitor role was retained under the Mental Health (Compulsory Assessment and Treatment) Act 1992, in 2014, 14 years after the Act was passed, no official visitors had been appointed.[236]

277. After 1992, there was a legislated complaints process for people in care who were subject to compulsory assessments and treatment orders.[237] It was limited to complaints about breaches of their statutory rights, but did ensure patients had access to advocacy, and that all complaints were to be independently investigated by either the district inspector or official visitor.[238]

278. From 1996, the Code of Health and Disability Services Consumers’ Rights made it clear that anyone in the care of a service provider had the right to complain.[239]

People in care faced barriers and needed family, whānau, or advocacy support

279. In many mental health settings, families were actively discouraged from visiting their loved ones in care and other forms of family contact were restricted.[240] At times, care was taken to ensure the abuser’s reputation was protected.

280. In mental health settings, it was left to each setting to develop its own policies on reporting to police. The Inquiry heard evidence that across multiple settings there was a reluctance by staff to involve police in complaints of abuse and neglect.

281. Prior to 1992, complaints were not routinely recorded in mental healthcare settings. When recorded, they were often not reflective of what had happened, and were dismissive of the abuse complained of. There are limited records regarding complaints made to relevant professional bodies.[241]

Oversight and monitoring did little to change the experiences of people in care

282. The Mental Defectives Act 1911 set out the monitoring and oversight of people experiencing mental distress. The Act provided for an Inspector-General of Health, District Inspectors and Official Visitors as necessary.[242] These three roles represented the entire oversight and monitoring mechanism for mental health hospitals until the establishment of the Human Rights Commission, Children’s Commission, and the Health and Disability Commission in the 1990s.

283. The Inspector-General of Health was responsible for the general administration of the Mental Defectives Act.[243] District inspectors were acknowledged in a 1983 policy proposal as “one of the few legislative safeguards available to patients in the mental health system.”[244] This safeguard was applied inconsistently and with little direction from the Department of Health.

284. The Inquiry saw evidence that when district inspectors raised concerns these were not always taken seriously.[245] Patients were not always aware of the role of district inspectors or how to access them.[246] Survivors confirmed the lack of awareness regarding district inspectors. Ms ON, who spent time at Claybury House at Kingseat Hospital in Karaka, explained:

“I had never considered that there were people out there whose job description included keeping us safe.”[247]

285. At the beginning of the Inquiry period, the role of official visitors in monitoring mental health hospitals was already well-established, having been provided for in legislation since 1846.[248] Official visitors could visit any hospital in the area they were responsible for, without previous notice, as often as they thought fit, but had to do so at least once every three months and this increased to once a month for inpatients in 1992.[249]

286. Official visitors’ reports highlighted issues to hospital management like neglect and inadequate facilities, including no privacy in the toilets and poor-quality food.[250]

287. There were various issues with the effectiveness of official visitors, like patients being unaware of their existence or viewing them as part of the hospital system. Hospitals’ management sometimes took a hostile approach to official visitor’s reports and recommendations.

288. The lack of independence, definition and direction for both the district inspector and official visitor roles reduced the potential effectiveness of these roles and contributed to abuse in care.

289. In 1994, the Health and Disability Commissioner Act was enacted to establish the role of an independent Health and Disability Commissioner, an independent advocacy service, and to provide for a Code of Health and Disability Services Consumers’ Rights.[251] The Health and Disability Commission provides nationwide, gGovernment-funded, independent advocacy through the Advocacy Service for consumers of health and/or disability services who want to make a complaint regarding a breach of their rights under the Code of Health and Disability Services Consumers’ Rights.[252]

The State’s responsibility for care

290. Throughout the Inquiry period, specific State officials had statutory responsibilities to and were accountable for the treatment of people in their care, including in mental healthcare settings.

291. Many of the people in policy leadership roles lacked diversity and lived experience of what it was like to be in care. [253] Most leaders within the State in the Inquiry period were Pākehā, non-disabled men. This lack of diversity and lived experience of care in the State’s leadership contributed to discriminatory policy and legislative design and decisions that did not meet the diverse needs of people in care.

292. The State often failed to provide concrete support or special measures to families, whānau or parents in need, which affected their ability to care for their loved ones at home.[254] The State often failed to adequately explore other community or family-based options that prevented the need for out-of-whānau care.[255]

293. Discriminatory legislation, policies and practices reflected the views and attitudes of the people who designed them.[256] By and large, decision-makers lacked diversity and lived experience of care.[257] The perspectives of children, young people and adults in care were largely not considered in the design of legislation, policies and practices that affected them.

294. The Inquiry saw that the State attempted to make some changes to prevent and respond to abuse in care. However, despite changes to legislation and policies, instances of abuse in care have persisted, in part due to the ongoing discrimination towards those with care needs.

295. Some changes, like the closing of large institutions, took decades to achieve and had a marked impact in reducing rates of abuse and neglect. However, a switch to community-based care did not address the continuing discrimination and stigma within the mental health sector.

296. In settings like mental healthcare there were successive calls for change from families, whānau, communities and advocacy groups. The State, however, was slow to implement change and generally left decision-making powers to institutions themselves. It was not until 1992 that the State set legislative protections for people subject to compulsory treatment.

297. While deinstitutionalisation of care was an important step taken in the Inquiry period, there many years of institutionalising people suffering mental distress away from the families, whānau and communities. The push for deinstitutionalisation began in the late 1950s but it was not until the 1970s that these ideas finally began to take hold. Even then, the State was slow to make real change.

Society’s responsibility for care

298. The Inquiry heard that attitudes of ableism have directly contributed to people experiencing mental distress entering care and suffering abuse and pervasive neglect in care during the Inquiry period.

299. 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.”[258]

300. Ableism underpinned the views of disability throughout the inquiry period, and disablism was inherent within all care settings.[259] Throughout the Inquiry period limited understandings of neurodiversity, traumatic brain injury and foetal alcohol spectrum disorder (FASD) contributed to survivors entering and suffering abuse and neglect in care.

301. The Inquiry heard that ableism and disablism was embedded in Aotearoa New Zealand society,[260] and that ableist attitudes contributed to policies of institutionalisation that resulted in the invisibility of disabled people, including people experiencing mental distress, throughout the inquiry period. The Inquiry also heard that the whānau of disabled people were not adequately supported with resources and investment to ensure they could care for disabled family members, and that communities were not reasonably or adequately funded to provide supports and deliver programmes. This included the whanau of people experiencing mental distress.

302. At the Inquiry’s Ūhia te māramatanga Disability, Deaf and Mental Health Institutional Care Hearing, expert witness Dr Brigit Mirfin-Veitch explained that:

“understanding how social structures impact on and shape disability, violence and abuse also requires recognition that the way society works is framed by privilege and power, which is embedded in our economic and political and social policies and practices, that focus on the dominant and most productive members of society.”[261]

303. Segregating and congregating people experiencing mental distress in care institutions, away from their whānau, where they continued to be stigmatised demonstrated that they were not valued equally with able-bodied people. People experiencing mental distress in care were denied inclusion and participation. Education opportunities were limited and neglected. People in mental healthcare settings were generally unable to develop their independence or their unique gifts and strengths. Being kept away from their whānau and community exacerbated this.

304. Congregating people on perceived disability also led to assumptions of similarity between individuals, and people were not treated and cared for as individuals. This resulted in society continuing to disempower children, young people and adults in care who were experiencing mental distress from participating in decision making processes.

Lessons identified and changes made

305. 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.

306. 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.

307. 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.

308. 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.

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