Te aroturuki me te aronga kore 
Monitoring and oversight

He iti noa iho ngā aronga koretanga a te Kāwanatanga         
There was minimal oversight by the State

87.      There was minimal oversight by the State of State wards at Marylands and Hebron Trust.

88.      The Department of Social Welfare and Department of Education’s Child Welfare Division did not adequately monitor State wards placed at the school to ensure children were safe, happy and thriving. Neither the Department of Social Welfare or the Department of Education’s Child Welfare Department audited or inspected the school^[970] as there was no requirement to do so. The Department of Education was required to monitor the school in accordance with the regulatory framework governing private schools under the Education Act. Before 1964, inspections were required annually and from 1964 onwards, once every three years. The Ministry of Education was only able to locate records of two inspection reports for Marylands carried out by the Department of Education for the years Marylands was operating between 1955 and 1984.

89.     Many survivors had no memory of any contact with a social worker while at Marylands. Mr HZ said he had no recollection of talking to social workers while at the school. Indeed, the only outside adults he had contact with were “the women who cooked for us and looked after the dormitories”.^[971]

90.     In some cases, even the initial placement at Marylands appears to have been poorly considered, with some survivors questioning why the State allowed them to be placed at Marylands when they did not identify as having a disability.

91.      Trevor McDonald was among the group of boys that were transferred from the orphanage to Marylands. Like the others, he did not identify as having a disability. There is no evidence to suggest that the State questioned the suitability of placing non-disabled boys who had aged out of the orphanage, at Marylands.

92.     Trevor described feeling that the purpose of their placement was not to receive education or training, but to support the running of Marylands:

“We were in the wrong place at Marylands, we had no disabilities but other children at Marylands did”.^[972]

“Marylands was a school for children with learning difficulties. The boys who made up the initial roll and I had no disabilities though. We were only there to look after the other kids and to work for the brothers.”^[973]

93.     Some social workers considered they had only a limited role in supervising boys who were placed at Marylands or the orphanage, even for those in State custody.^[974] One social worker noted on the file of a State ward that he was “nominally on the case load only as he is living at [the orphanage]“.^[975] Typically, boys sent to Marylands by the State had a child welfare officer or social worker in their home district,^[976] and the Department of Social Welfare’s Christchurch district office acted as a ‘go-between’ for the school and the home district social worker.^[977] Home district social workers were apparently responsible for visiting and reporting on such boys,^[978] and the Christchurch district office was responsible for arranging annual progress reports from the school and passing these to the home district officer.^[979] Cooper Legal said communication between the Christchurch district office and the home district officer sometimes completely broke down.^[980]

94.     Peter Galvin from Oranga Tamariki told us home district officers had to visit State wards at least once every four months, although they were expected to visit weekly at the start of a placement, reducing to perhaps fortnightly and eventually four-monthly visits.^[981] The reality, as evidenced by a review of a sample of files, was that social workers on average only met the minimum requirement of three visits a year. In addition, social workers’ monitoring visits did not always take place at Marylands itself. They could also take place in a boy’s home district when he was back for holidays.^[982] Mr Galvin said most apparently did.^[983] The policy was four-monthly visits to the school, but, in practice, social workers’ visits were geared around the school holidays.^[984] Social workers might make two ‘visits’ during the holidays, then none for a long time afterwards.^[985]

95.     According to Cooper Legal, social workers viewed these home visits as ‘check-ins’. Social workers saw State wards when they returned to their home district for holidays and essentially that counted as a visit to check up on how the boy was doing at both home and at Marylands.^[986]

96.     Social workers who visited Marylands did not always see every boy on their caseload, and they rarely spoke to boys without a brother present.^[987] The Department of Social Welfare did not suggest or require social workers to speak to a boy away from the brothers.^[988] Cooper Legal said few of its clients ever recalled social workers speaking to them at the school and certainly not without a brother present.^[989] It said a Christchurch-based social worker also had some oversight of the school and would sometimes visit, but the records were unclear about whether this person spoke to the boys on their list.^[990]

97.      Mr Galvin said the Department of Social Welfare and the Department of Education’s child welfare division were under no obligation to visit children and young people who did not have some formal legal status with them.^[991] Survivor Danny Akula said the Ministry of Social Development concluded no breach of duty of care or practice failure had occurred over his placement at Marylands because he had no formal status with either State agency at the time. But he said Cooper Legal described this argument as self-serving and one put forward by the ministry every time the extent of the Department of Social Welfare’s duty of care was tested before the courts. He also said Cooper Legal “pointed out that such arguments had failed in previous cases before the courts”.^[992]

98.     Another survivor, Steven Long, told us social workers visited him “every now and then” at Marylands, but “never” spoke to him alone or asked if he was happy and well cared for. He said social workers “just relied on what the brothers told them about how I was getting on, even though I was a State ward.”^[993]

99.     Hebron Trust, on the other hand, was a third-party provider, and was approved as a Child and Family Support Service under the s396 Approval Scheme of the 1989 Act, which formalised a process where the Department of Social Welfare used third-party programmes to care for children. From 1992, Hebron Trust was approved as an accredited provider under the Community Funding Agency within the Department of Social Welfare. Cooper Legal described the requirements placed on the third-party providers:

“Under the 1989 Act, programmes or organisations had to meet a number of requirements before they could be contracted, and paid, to care for children who were under the custody or guardianship of CYFS. The scheme also provided for complaints to be investigated and the approval of an organisation suspended or cancelled, if necessary. While this sounded good in theory, the practice sometimes went horribly wrong.”^[994]

100.   Cooper Legal detailed the difficulties between the state and the third-party providers with regards to monitoring:

“The division between ‘front line’ social workers and the Community Funding Agency created different measures of expectation. Complaints were not properly investigated and, even when complaints were substantiated, programmes continued to be used to care for children. Further abuse was the inevitable result.

The use of these kind of organisations has, at times, caused MSD to say it is not responsible or liable for the things that happened to people on these programmes. This is even where the children or young people were in the custody or under the supervision of CYFS, and where CYFS approved the programmes.”^[995]

101.   A survivor, Justin Taia , said he was under the supervision of the Department of Social Welfare while at Hebron Trust house, however he was not assigned a social worker for most of the 12-month period, during which he was being sexually abused by Brother McGrath.^[996]

102.   Mr Galvin detailed the complaints policies required by Hebron Trust, however, that there was no obligation for accredited providers to notify the Community Funding Agency:

“The CFA Level One Standards in 1992 required the Hebron Trust to have a clear and understood grievance procedure for dealing with complaints from children, young people and families and a clear policy for dealing with any client’s allegations of abuse from staff and caregivers. There does not appear to be a requirement in the CFA Level One Standards for Approval for a service provider to notify the CFA of any allegations or concerns received.”^[997]

103.   Mr Galvin said that between 1990–1992: “it wasn’t necessarily our social workers who were working with those children [at Hebron Trust].”^[998] However, we know that live-in social workers employed at Hebron Trust were funded by the Department of Social Welfare.

Ētahi atu wā kāore te Kāwanatanga i noho ki te āta whakatikatika

Other missed opportunities for State intervention

104.   Police picked up boys who ran away from Marylands and returned them, without keeping proper records about these events, and without asking or investigating why the boys were running away. Mr AL recalls running away often but was usually picked up by police and then disciplined by the brothers on their return. Mr AL said:

“I can remember being found by the police and returned to Marylands. On our return, we were physically disciplined by Brother Berchmans.” ^[999]

105.   Mr HZ and other boys ran away and went to the police station to report the abuse. They were disbelieved and returned to Marylands by police. It appears that no one believed survivors or took any action.^[1000]

Ngā hautūtanga a te rangapū ki whenua kē 
The Order’s leadership based overseas

106.   The province’s two most senior leaders (Prior General and Provincial) were based in Rome and Australia respectively. This distant and intermittent oversight meant brothers in Christchurch were not closely supervised. There was little risk that their behaviour would be uncovered. It also meant that children, young people and their whānau were less able to disclose their abuse and neglect to the Order.

Te Pīhopa Katorika o Ōtautahi        
The Catholic Bishop of Christchurch

107.   The presence of the Order in Aotearoa New Zealand was facilitated by the Bishop of Christchurch:

›      The Order expanded from Australia to Aotearoa New Zealand in 1954 at the invitation of the New Zealand Catholic Bishops.

›      In 1954, Bishop Joyce consented to the Order setting up a school for disabled boys in Christchurch. He officially offered the Marylands site to the Order and later transferred the property to the Order.^[1001]

›      In 1955, Bishop Joyce successfully lobbied the State resulting in an increase in funding of Marylands School.^[1002]

›      In 1983, Bishop Ashby accepted the Order’s request to withdraw from Marylands and transfer the running of the school to the Department of Education.^[1003]

›      In 1986, Bishop Hanrahan attended a planning meeting held by the Order about whether, and in what form, it should continue to operate in Aotearoa New Zealand.^[1004]

›      Bishop Hanrahan later invited the Order to establish a youth ministry in Christchurch, which led to the establishment of Hebron Trust.^[1005]

›      Bishop Hanrahan sought funding for the work, largely through community grants and later State funding for staff and other costs.^[1006]

108.   To the extent required, the Bishop of Christchurch failed to provide adequate oversight over the Order’s operations at both Marylands and Hebron Trust.

109.   In addition, once the reports of abuse became public knowledge in 2002, Bishop Cunneen failed to take any responsibility for the Order’s conduct. Instead, he expressed discontent for the media attention and spoke out to protect the reputation of the church. Bishop Cunneen issued a public statement that he felt “saddened by the inaccuracies and lack of balance in some of their reporting.”^[1007]

110.   Dr Mulvihill told the Inquiry that there was no attempt made by Bishop Cunneen to assist the Order when Br Burke and Dr Mulvihill were responding to the allegations and nor any assistance to provide adequate redress. Dr Mulvihill spoke to Brother Burke after he met with the Bishop. She recalls that: “Brother Burke was upset after the meetings as a result of the Bishop’s unwillingness to become involved.”^[1008]

Ngā āhuatanga hāngai
Relational Factors

111.    Sexualised behaviour and abuse was normalised between the brothers and the children. There was a power imbalance in the relationships between the children placed in care at Marylands, Hebron Trust and the orphanage, including survivors of abuse, and other people in the care systems, including the brothers, nuns, social workers, the State, officials and parents.

Whanonga āki taihemahema me ngā tūkinotanga i noho māori i waenga i ngā parata me ngā tamariki 
Sexualised behaviour and abuse normalised between the brothers and children

112.   Harmful sexual behaviour and abuse was rampant in the culture of how Marylands and Hebron Trust operated. It was openly tolerated and to a certain extent regarded as normal, despite the fact it was contrary to the law, societal morals and the Order’s vow of chastity.

113.   In some cases, sexualised behaviour occurred even during the brothers’ training. Brother McGrath told police he was groomed and sexually abused by Brothers Moloney and Berchmans during his own training with the Order.

114.   Mr AR, a former brother within the Order described his experiences during training:

“It was all just in my face – erect penises everywhere and love letters to other brothers. It was almost like I was meant to see these things. I think this was a form of grooming and it was totally inappropriate. We were living in a novitiate: a place where men … are supposed to go to become holy.”^[1009]

115.   At Marylands, sexual abuse was commonplace, and sometimes deliberately took place in plain view of others. Mr HZ, a survivor, said he believed this sexualised culture probably contributed to the collusion among brothers in sexually assaulting boys at the school and orphanage.^[1010]

116.   Boys sexually abused by brothers began to abuse other boys, multiplying the number of victims. Many people knew about the abuse, and knowledge was widespread among Marylands students. One survivor, James Tasker, said he was aware from the outset that a “huge amount” of sexual behaviour occurred between the brothers and the boys and between the older and younger boys.^[1011] Another survivor said Brother McGrath and Brother Moloney ’normalised‘ such sexual abuse, and he “became involved in similar sexual activity with other boys”:

“The brothers would make us boys perform sexual acts on each other. This included sexual fondling and oral sex … At the time I thought that this must be exactly what boarding school was like, because it was so common and normal at Marylands. Looking back at it now, I realise that this isn’t normal behaviour … sexual indecencies between the boys were common and this behaviour occurred even when the defendants were not present. It seemed ‘normal’ and I was often involved in this type of behaviour.”^[1012]

117.    At Hebron Trust, it was well known between the residents that Brother McGrath would sexually abuse newcomers.

118.   Mr IS told the Inquiry that not long after his first week at Hebron Trust, he was approached by another resident regarding Brother McGrath’s sexual advances:

“Back at Halswell Road, I remember one of the Hebron boys asking me if I have had a ‘special cuddle’ from Brother Bernard yet. I had no idea what he was talking about.”^[1013]

Mana titoki
Power and control imbalance

119.   The brothers and staff at Marylands exercised full control over the day-to-day lives of the children at Marylands. They told them when and what to eat, when to sleep, when to work and when they could see members of the outside world, including their parents and wider whānau. The brothers abused this control, creating an environment of terror and fear, strengthening the power imbalance.

120.   A further imbalance existed between the children and young people and the system itself, the church and the State. At Marylands and the orphanage, the boys’ only access to the State, was the occasional social worker and police, who often failed to act on reports of abuse. The children and young people were not given a voice, they were not asked what they wanted or needed and more importantly, they were not asked if they were safe.

Ngā take ā-whānau, ā-takitahi
Individual and whānau factors

121.   There were factors relating to individuals and the disempowerment of children and their whānau, specifically:

(a)      the behaviours of the abusers

(b)      barriers faced by survivors and their lack of rights and voice

(c)      discrimination and disempowerment of children, especially disabled children

(d)      disempowering of whānau in decision-making.

Ngā whanonga o te kaihara
Abuser behaviour

122.   The behaviours of the abusive brothers were predatory, deliberate, manipulative, and showed a complete disregard for the powerlessness and vulnerability of their victims for their own sexual gratification.^[1014]

123.   They were educated, and fully appreciated the gravity and wrongfulness of their actions using many techniques to ensure a victim’s silence.^[1015]

124.   They were able to exploit the safeguarding inadequacies within the systems at Marylands and Hebron Trust.

125.   Their behaviours appeared to be endorsed by the wider approach of the church through the minimisation of crimes, the secrecy of confession, and an “act of contrition or reconciliation with God” over punishment or prevention of further abuse, including through a complete lack of reporting to police.

126.   The manipulation extended beyond the boys and in Brother McGrath’s case, young people, to the whānau and the wider Christchurch community. The abusive brothers were not only able to carry out and disguise the sexual abuse, but the perception of them was also as exceptional, upstanding members of society.

Ngā whakapōreareatanga i rangona ai e ngā purapura ora, te takahi mana me te toihara 
Barriers faced by survivors, discrimination and disempowerment

127.   Society devalued children and young people, and as a result, placed no weight on what they had to say. Māori and disabled children were further devalued by society, resulting in a complete lack of voice or agency.

128.   In contrast, there was societal and political deference to the church, and those who represented it. When the church spoke, it was unquestioned. When a child spoke, they were silenced or ignored. This created a significant barrier for the children and young people who were being abused by those in the Order.

129.   Some boys who were able and managed to find a voice to tell those in positions of power, including social workers, the police and teachers, were not believed, and were told so. Nothing was done in response to these disclosures, reinforcing that they had no power in speaking out. Many times, such disclosures resulted in further abuse and/or punishment.

130.   Children in the care of the Order were labelled as having a disability, despite never being diagnosed. These children and disabled children, or children with learning difficulties, also had no voice, and disclosures went unbelieved or were blamed on their perceived misunderstandings. Some children had no means of communicating, and expressed what was happening to them behaviourally. They were simply labelled as delinquent and not worthy of a voice or rights.

131.   The criminal justice system made little allowance for the special circumstances and communication support needs of people with disabilities appearing as witnesses in prosecutions.

Te tāmi i te mana o te whānau ki te whakatau take 
Disempowering whānau in decision-making

132.   Whānau, hapū and iwi were disempowered to make decisions for their tamariki, and rangatahi. This occurred through the State taking control, removing their children and placing them into care. The iwi, hapū and whānau had no voice or involvement in the decision-making process and were often left powerless. Hapū were unable to exercise tino rangatiratanga over its whānau, tamariki and rangatahi.

133.   In addition, disempowerment came from the lack of alternative options. Whānau of disabled children or children with additional support and learning needs, had no local school or home-based support (either financially or physically), and often no alternative options outside institutionalisation.

He kōrero whakakapi
Concluding Statement

134.   Sexual abuse as depraved and deep-rooted as that uncovered during our investigation could only exist, flourish and go unpunished in an institution whose culture was as out of touch with everyday morality as the actions of the perpetrators themselves.

135.   The combination of all factors outlined above, working together in unison, created the ‘perfect storm’ where abuse and neglect was able to occur at extreme levels, no one was able to identify what was happening and if they did, no steps were taken to address it.

Nga Whakakitenga: ngā take i takakinotia ai ki ngā mahi tūkino me ngā whakangongo i te wā o te noho taurima 
Findings: Factors that caused or contributed to abuse and nelgect in care

136.   The Royal Commission finds many factors together, contributed to abuse and neglect being able to occur for decades across Marylands and Hebron Trust.

Ngā take papori      
Societal factors

137.   The societal factors that the Royal Commission finds caused or contributed to abuse and neglect in care are:

a.         At times, society idealised the church and those who represented it were revered, resulting in a misplaced high trust of the Order by the State, the public and whānau. This resulted in the church, the Order and the brothers holding a degree of impunity.

b.         Social attitudes and a lack of understanding of sexual abuse of boys and disabled children prevented and delayed the disclosure of abuse.

c.         Social attitudes, evident in regulatory frameworks, were reflective of eugenics, ableism, disableism, discrimination and institutionalisation of disabled children or children with any learning support needs.

d.         Racism and discrimination, particularly towards tamariki and rangatahi Māori, were continued in the Order’s institutions, evident in targeted racial abuse and neglect.

Ngā take whakahaere
Institutional factors

138.   The institutional factors that the Royal Commission finds caused or contributed to abuse and neglect in care are:

a.         There was a lack of monitoring and oversight by the State, the Order and the church from the date of application to establish Marylands and the development of Hebron Trust, until Brother McGrath’s departure.

b.         There were inadequate safeguarding policies for the tamariki and rangatahi at Marylands and Hebron Trust.

c.         The State failed to act on abuse disclosures by the boys to social workers and police. Tamariki and rangatahi Māori and disabled boys in particular, were not understood or believed.

Rangapū Katorika  o Hato Hoani o te Atua
Hospitaller Order of St John of God

139.   The factors that the Royal Commission finds the Order caused or contributed to abuse and neglect in care are:

a.         The Order in Aotearoa New Zealand had, at times, a culture of normalised, sexualised and abusive behaviour and sometimes perceived child abuse as a sin that could be forgiven, rather than a crime.

b.         The Order valued its reputation, its institutions and its brothers above all. A strong hierarchy within the Order perpetuated a culture of silence.

c.         The State and the public were successfully convinced that the Order was operating a superior facility, which was the best place for boys, disabled boys and rangatahi, to give them the strongest chance of positive life outcomes.

d.         The Inquiry saw no evidence brothers and teaching staff possessed the necessary skills and expertise to: care for or teach children; support disabled children or those with learning support needs; understand te ao Māori; te reo Māori or te Tiriti o Waitangi nor the nature of the relationship between the Crown and Māori.

Ngā parata o Hato Hoani o te Atua
The St John of God brothers

140.   The factors that the Royal Commission finds the brothers caused or contributed to abuse and neglect in care are:

a.         Some brothers within the Order exploited religious beliefs, fear of God and religious teachings to abuse and prevent disclosure of that abuse.

b.         The abusive brothers were predatory and manipulative, deliberately targeting at-risk children and young people and exploiting safeguarding inadequacies for their own sexual gratification.

Ngā tamariki i tukinotia
Children exploited

141.   The factors that the Royal Commission finds that caused or contributed to abuse and neglect in care of exploited children are:

a.         The environmental, emotional and cultural removal of tamariki from whānau and communities and placement in the physically remote Marylands and the orphanage, meant that in the event of abuse or neglect, disclosure opportunities were reduced.

b.         Children, especially tamariki Māori and disabled children, were undervalued, had no voice and were not understood or believed.

c.         The Order and its brothers had control over every aspect of the children and young people’s lives. Tamaraki, rangatahi and their whānau, hapū and iwi were disempowered from being involved in decision-making.