The State and faith-based institutions must take accountability for the “pervasive” abuse of thousands upon thousands of babies, children and adults in care and put right the wrongs of the past.   

The State must urgently fix the “national disgrace” and “fully funded failure” that led to pervasive abuse everywhere the Abuse in Care Royal Commission of Inquiry looked.   

The Inquiry’s final report and recommendations, Whanaketia – through pain and trauma, from darkness to light, were published today.  

Whanaketia’s 16 volumes cover the context in which abuse occurred, what happened, why it happened, specific case studies, survivor experiences and recommendations. The Inquiry also presents its vision for the future, called He Māra Tipu (a growing garden). 

Over the past six years, the Inquiry has been investigating the abuse and neglect of children, young people and adults in State and faith-based care from 1950 to 1999. The Inquiry also heard from people abused from 1999 up until the present day. The Inquiry had the widest scope of similar inquiries around the world.  

In Whanaketia, Commissioners Coral Shaw (Chair), Dr Anaru Erueti and Paul Gibson QSO say that State and faith-based leaders “failed in their duty” and “failed to hold abusers to account.”  

“Internationally, Aotearoa New Zealand is often seen as a beacon of human rights and liberal progress. New Zealanders are proud of our country’s worldwide reputation for fairness, justice, and the protection of individual freedoms. However, this image contrasts starkly with our domestic reality, where we have a terrible track record of abuse and neglect in care settings,” Commissioners said in Whanaketia. 

Many of the factors that contributed to abuse and neglect are not confined to the past; they are present today. The Inquiry’s report says fundamental changes are needed to safeguard the children, young people and adults who are in care today.  

Among the Inquiry’s 138 recommendations, is a new national care safety regulatory system – backed with a new law – to protect people in care. Just as the Pike River tragedy led to WorkSafe, the pervasive abuse the Inquiry has uncovered must lead to a Care Safe Agency, responsible for preventing and responding to abuse across all State and faith care settings.  

Faiths would be held to the same standards and rules as every other organisation providing care.  

The Inquiry’s vision for the future would see “people in care empowered and supported through investment.” The Inquiry does not see Oranga Tamariki as part of the vision. 

“Significant resources have been used to deny survivors their voice and to defend the indefensible. This must stop.” 

Commissioners call for the implementation of all the recommendations, mobilised by cross-party support. Commissioners say failure to implement some of the recommendations will create gaps and points of weakness that abusers could exploit.  

The report finds abuse did not occur solely due to the actions of a few ‘bad apples’, but that it was deeply rooted and enabled across all levels of the systems responsible for providing care.  

Population groups were targeted because of their identity – including Māori, Pacific Peoples, Deaf and disabled people, neurodiverse people, people who experience mental distress, Takatāpui, Rainbow, and MVPFAFF+, and girls and women.  

Abuse against babies, children, young people and adults in care contributed to, and in many ways created, the ‘care to custody’ pipeline and the formation and entrenchment of gangs in Aotearoa New Zealand, costing society both in terms of victimisation and the direct costs of policing and imprisonment. 

The abuse has contributed to an intergenerational transfer of inequities. This includes poorer physical and mental health, education and employment outcomes, family and intimate partner violence, and substance misuse and abuse. One of the greatest costs is the loss of generations of adults who could have positively contributed to their whānau, community and the country.  

The average lifetime cost to a survivor of things that New Zealanders consider normal day-to-day activities was estimated in 2020 to be approximately $857,000.    

The estimated total economic cost of this abuse and neglect between 1950 and 2019 is around $200 billion. The Inquiry estimated this is three times what the government spent on war and rehabilitation during World War Two, three times the cost of the government's COVID-19 response, and over four times the cost of the Canterbury earthquakes response and recovery. In fact, the estimated cost of abuse and neglect is more than all those events combined.  

Whanaketia: through pain and trauma, from darkness to light can be viewed on the Abuse in Care Royal Commission of Inquiry’s website: www.abuseincare.org.nz/whanaketia

Whanaketia can be found in pdf, html and word formats at www.abuseincare.org.nz/whanaketia 

The executive summary is also available in a range of alternative formats: 

• Te Reo Māori  

• Video with subtitles  

• Large text  

• Audio version  

• Braille  

Further translations will be made available in the coming fortnight, including Easy Read and New Zealand Sign Language.  

Also available are summaries or guides of the experiences of:   

• Māori survivors  

• Pacific survivors  

• Survivors of faith-based care settings  

• Women and girls  

• Takatāpui, Rainbow and MVPFAFF+ survivors  

• Disabled survivors  

• Deaf survivors  

• Survivors of mental health care settings 

Other documents will be published on the Inquiry website in the coming weeks including translations of the executive summaries of the Settings Case Studies. 

The work of the Royal Commission is now complete. The Chair and Commissioners cannot make further public comment on the report. 

The State’s role  
The State was ultimately responsible for the care system. Successive Government ministers and heads of government agencies who were responsible for the law and policy settings had accountabilities in law that they failed to uphold.  

Instead of addressing the social and cultural needs of families and whānau by resourcing and empowering them to care for their own, the State placed children, young people and adults in punitive, institutional settings that segregated and isolated them – out of sight and out of mind. 

Critical rights, such as those guaranteed to Māori in te Tiriti o Waitangi, and human rights, that should have protected people in care, were ignored or overlooked altogether.  

Political and public service leaders spent time, energy and taxpayer resources to cover over abuse and neglect, and then legally fight survivors to protect the potential perceived costs to the Crown, and their own reputations. There was limited independent oversight or monitoring of State and faith-based care.  

The role of churches and faith-based institutions  
Churches and faith-based institutions had unique factors that contributed to abuse and neglect in their care. The assumed moral authority and trustworthiness of clergy and religious leaders allowed abusers in faith-based institutions to perpetrate abuse and neglect with impunity.  

Religious beliefs were often used to justify the abuse and to silence survivors. Abuse was treated as a religious transgression that required survivors to forgive, let go of anger and blame, and instead embrace those who had sinned against them; and abusers to merely repent.   

Faith leaders fought to cover up abuse by denying culpability and moving abusers to other locations.  

The abuse was unimaginable  
Of the estimated 655,000 children, young people and adults in care from 1950 to 2019, it is estimated that 200,000 were abused and even more were neglected.  The true number will never be fully known. s 

Perpetrators took advantage of their positions of power. They were skilled at exploiting the gaps and failures in the care system.  

Those in care were devalued and dehumanised because of society’s discriminatory attitudes towards difference – through racism, ableism, disablism, sexism, homophobia, transphobia, and punitive attitudes towards whānau and individuals who need support.  

Survivors faced physical, emotional, mental and sexual abuse, severe exploitation and neglect. 

• Physical abuse was prevalent across all settings. In some cases, staff went to extremes to inflict as much pain as possible using weapons and electric shocks. Abusive and uncaring language, shaming and humiliation and psychological harm were used to intimidate and humiliate. 

• Staff often pitched children against each other and encouraged peer-on-peer abuse, including vicious attacks and humiliating rituals.  

• Sexual abuse was commonplace. Many survivors were sexually assaulted, raped and forced to perform sexual acts. Sexual abuse was used to punish and intimidate. Abusers groomed survivors into trusting them; they groomed other staff and leaders to gain trustworthiness. 

• Medical abuse included chemical restraint to control behaviour, improper medical treatment, and medication or equipment misuse and treatment without consent, including electric shocks. 

• Women and girls were routinely tested for sexually transmitted infections and were often forced to have degrading internal vaginal examinations. Clinicians would sometimes use medical checks as an opportunity for sexual abuse. 

• Survivors were put in seclusion rooms, in often cold, dark, and unhygienic conditions. They were held for days, weeks or even months. They were at risk of sexual and physical abuse by staff. 

• People with military backgrounds were assumed to be appropriate carers, and many brought a culture of command and control, punishment, physical violence and verbal abuse. 

Recommendations for the future   

Whanaketia calls for a complete overhaul of Aotearoa New Zealand’s care system in social welfare, disability, mental health, education, and transitional and law enforcement, and pastoral care settings.   

The ultimate goal is to ensure that no individual experiences abuse or neglect and that whānau receive the necessary support to lead fulfilling lives.   

There are three key themes to the report recommendations.  In summary:  

1. Righting the wrongs of the past through:  

• The State and faith leaders making public apologies and taking accountability for the harm caused to survivors  

• Making the justice system safer and more accessible for survivors  

• Urging the State and faiths to implement the puretumu torowhānui system and scheme without further delay  

2. Making care safe through:  

• Creating a single independent safeguarding agency and a new law  

• Faiths and their leaders will have to abide by the same laws, rules and accountabilities as everyone else  

• Having consistent and comprehensive rules and standards to keep people in care safe  

• Having real sanctions and penalties in law to hold people and organisations to account  

• Having a safe and well-trained workforce  

3. Entrusting and empowering communities through:  

• Shifting from State care to communities caring for each other  

• Giving everyone in Aotearoa New Zealand the knowledge and tools to contribute to preventing abuse and neglect  

• Upholding people’s rights to prevent abuse and neglect  

He Māra Tipu – a Vision for the Future 

The Inquiry was explicitly prevented by Government changes to its Terms of Reference in July 2021 from examining or making any findings about current care settings. It was allowed to hear from people who were in care after 1999, including people currently in care. The evidence the Inquiry heard, including about survivors’ issues and experiences after 1999, suggests that the factors that caused or contributed to abuse in the past endure today. This is backed up by the observations and conclusions of many reviews and reports on care settings released over the last 25 years. 

Whanaketia sets out the Inquiry’s vision for the future – he Māra Tipu. The foundation of this vision is the dreams (moemoeā) shared by survivors for the future.  

To reach he Māra Tipu, a total overhaul and fundamental change to care is needed. The State would need to hand over power, funding and control of care supports and services to collectives and local communities (like NGOs, community organisations, hapū, etc). This would start with devolving the care settings that the Inquiry investigated – social welfare, disability, mental health, education and transitional and law enforcement settings. At the same time, government agencies currently designing and delivering care (including the Ministry of Health, Whaikaha and the Ministry of Education) would downsize and shift focus to supporting collectives and local communities. The Inquiry does not foresee Oranga Tamariki as part of he Māra Tipu.  

These ideas are not new. They were called for more than 35 years ago by the Puao-te-ata-tu report. Other countries are already moving in this direction.  

The constraints of the Terms of Reference meant the Inquiry could not set out the full pathway to reach he Māra Tipu. Implementing the Inquiry’s recommendations in full are the first steps that Aotearoa New Zealand needs to take to start the journey to he Māra Tipu.