151. Kimberley Centre survivors suffered significant longterm impacts. The impact of prolonged and chronic neglect on children, young people and adults was insidious. For those who were children and  young people, the neglectful environment deprived them of their childhood. For all survivors it robbed them of their human promise – the opportunity to fulfil their potential.

152. This chapter describes the impacts of abuse and neglect that survivors of the Kimberley Centre reported to the Inquiry.

Survivors were impacted by the abuse and neglect they experienced

153. The Inquiry has heard of babies being placed in psychopaedic institutions from birth. The 1964 New Zealand National Film Unit documentary One in a Thousand shows images of babies and toddlers being fed, washed and placed in rows of cots in a large dormitory at the Kimberley Centre.[195]

154. Neonatologist Dr Simon Rowley provided the Inquiry with an expert opinion:

“Chronic neglect is associated with a wider range of damage than active abuse and unfortunately receives less attention in policy and practice throughout the developed world.”[196]

155. Dr Rowley explained that neglect adversely affects the brain development of babies and children. Brain cells that have developed in utero continue to connect and be sculpted by the experiences babies and infants have in early life. Looking and touching, feeding, cuddling, singing, rocking and other positive and affirming sensory experiences are very important for brain connectivity. An absence of this stimulation is a form of neglect and is possibly more detrimental to human development than the experience of negative stimuli. If neglect is prolonged, infants become apathetic and non-responsive.[197]

156. The Inquiry heard evidence that shows neglect was across all life domains for disabled children, young people and adults in disability and mental health institutions. Survivors experienced psychological and emotional neglect, and physical, cultural, medical and educational neglect. Dr Rowley concluded that when neglect is experienced across all of these life domains, that is pervasive neglect.[198] The longer the duration of neglect, the more severe the effects. Family members noticed regression while in care. The impact of pervasive neglect experienced during a lifetime of institutional living leaves some people unable to function independently.[199] The failure to create the necessary conditions for individuals to have their essential needs met[200] amounts to a failure to respect the right to human dignity and the inherent value of these individuals.

157. The impact of prolonged and chronic neglect of adults at the Kimberley Centre and other psychopaedic institutions was insidious. The rigid routines of the institutions denied adults of their personhood. The Inquiry heard evidence that these institutions were places of “… neglect of someone’s human promise or their potential”.[201] Researcher Paul Milner commented that if a parent had been displaying that kind of ambivalence and denial of personhood to a child there would have been grounds for the State to remove that child from the parent on the basis of neglect.[202]

158. Policies directed at the segregation of disabled people from society and their congregation in institutions have had lasting impacts on the outcomes for disabled people in modern society. Dr Ingham, a member of the Kaupapa Māori Panel at the Inquiry’s Ūhia te Māramatanga Disability, Deaf and Mental Health Institutional Care Hearing, told the Inquiry “There was very little opportunity within institutional care frameworks for people to be better off at the end of that care experience than they were beforehand. To come out with skills, vocational opportunities, that [sic] have been educated, to have gained experience in tikanga, te reo, these things were not part of a therapeutic process. These were primarily facilities of detention and isolation.”[203]

159. Survivors and their family members told the Inquiry about the long-term impacts they experienced from abuse and neglect at the Kimberley Centre. European survivor Sir Robert Martin said: “My life in institutions meant I personally had nothing, no one to call my own and I learnt how I was a nobody, that my life didn't really matter. I also learnt that I was somehow actually being punished for who I was.”[204] Sir Robert further told the Inquiry that the abuse he experienced and witnessed had a lifelong impact on him. Even as an adult, he got anxious and scared if people were yelling or screaming.[205]

160. Excessive medication had a significant impact on New Zealand European survivor Murray Newman’s personality. His brother David Newman told the Inquiry:

“It changed him … his behaviours became unpredictable and aggressive, and as he got older those behaviours magnified. Whereas previously, of course, he hadn’t been like that.”[206]

David attributes Murray’s increasingly aggressive tendencies and behaviours to the prolonged medication and physical abuse he was subjected to in institutional care.[207]

161. Excessive medication had a major impact on New Zealand European survivor Irene Priest’s life. She effectively lost 20 years of her life due to excessive medication, which took away her quality of life for this time. Irene’s personality has also been impacted, as described by her sister “The neglect and lack of love in Kimberley made Irene less trusting of people. It took away a lot of her loving and warm nature. In the past she would have been really happy to cuddle or give me a kiss, but now that does not really happen. There has been a part of that warmth that has gone from her life.”[208]

162. New Zealand European survivor Mr EI described the impact of moving from one unsafe institution to the next as like having your heart torn from you. He held all of this inside, and despite later counselling, everything has stayed with him. He is still triggered by things he reads, hears or sees on TV. He was robbed of his childhood, education and potential.[209]

Survivors and their whānau were impacted by their lifelong stay in the institution

163. Researcher Paul Milner noted in his evidence to the Inquiry that a lasting impact of the Kimberley Centre was that “perhaps most disturbingly, Kimberley forever displaced generations of men, women and children from the citizen selves they might have been and become”.[210] Many people spent the majority of their lives in the Kimberley Centre and died there.

164. Families were impacted by institutionalisation. Many carried the guilt of abandoning a family member when they later found out how that family member was treated at the Kimberley Centre.[211]

165. Unmarked graves were used to bury patients from psychopaedic and psychiatric institutions. If remains were not claimed by families, institutions regularly buried patients in private institutional cemeteries, such as the cemetery at Tokanui Psychiatric Hospital (south of Te Awamutu), or in ‘poor persons’ or ‘paupers’ graves’ in public cemeteries.[212] During the deinstitutionalisation of the Kimberley Centre, it was discovered that some people who had died while living at the Kimberley Centre had been cremated with their ashes buried in a rose garden at the Kimberley Centre. When the Kimberley Centre closed, there was a symbolic removal of some of the rose garden soil which was reburied at a local cemetery.[213]

Impact of transgression against whakapapa, lack of cultural access and identity

166. As explained in Part 4 of the Inquiry's final report, Whanaketia – Through pain and trauma, from darkness to light, the removal of survivors from their whānau, hapū and iwi is considered a transgression against whakapapa. In this case, the placement of tāngata whaikaha Māori in the Kimberley Centre away from their whānau, hapū and iwi can also be considered a transgression against whakapapa. Whakapapa can be translated as genealogy, lineage or descent. It is an essential element of belonging and identity. It is an attribute Māori are born with and provides them with identity within their whānau, hapū and iwi, and connects them to their tūpuna (ancestors), their atua (God) and to their tūrangawaewae (place of belonging).

167. Where links to their whānau, hapū and iwi were broken or discouraged, the identity of tāngata whaikaha Māori was either stripped away or considerably undermined – this had a significant impact on their lives. The lack of visibility and public scrutiny over the lives of whānau members in care and the loss of the ability to exercise rangatiratanga (self-determination) over the decisions impacting the lives of those whānau members, prevented those with kinship links from upholding their collective whakapapa rights and responsibilities to tāngata whaikaha Māori in care. This also increased the risk to tāngata whaikaha Māori as they were not only away from whānau, but whānau were unable to care for and have oversight of the care provided. Further, there was a broader loss of knowledge for iwi in terms of not having the stories of tāngata whaikaha Māori to share, and a loss of knowledge for whānau, hapū and iwi in terms of how to include disabled people in their communities.

168. The transgression against whakapapa had a broader impact on whānau and hapū. From Māori worldview, the wellness of an individual is intimately tied to the wellness of the collective. The care, protection and nurturing of a person’s whole wellbeing is the responsibility of the collective. The impact of abuse and neglect on the mana, tapu, mauri, wairua and rangatiratanga of an individual therefore must be seen in the context of a negative impact on the mana, tapu, mauri, wairua and rangatiratanga of the wider whānau, hapū and iwi.

169. The dislocation of tāngata whaikaha Māori meant there were limited opportunities for tamariki, rangatahi and pakeke Māori residents in the Kimberley Centre to build up knowledge of their cultural identity. They were effectively prevented from practising and connecting with te ao Māori and this negatively impacted on their cultural identity. Within the institution they lacked the support and access to cultural knowledge, tikanga and an environment nurturing of their cultural identity. This further compounded the transgression against Māori survivors’ whakapapa.

Survivors lost their ability to speak as a result of neglect in care

170. The level of neglect experienced at the Kimberley Centre resulted in some people entering the institution being able to speak but leaving the institution silent. Researcher Paul Milner told the Inquiry:

“Imagine the deprivations that would make you lose your language. That language had no use to you in an institution.”[214]

171. Observational research found that people were seldom spoken to at the Kimberley Centre and 63 percent of conversations never lasted longer than one minute.[215] Conversations were almost always initiated by staff and the intent was instructive. There was never any invitation to engage in deeper dialogue or something that would lead to a deeper knowledge of somebody’s personhood. These were silent places.[216]

Survivors experienced inadequate oversight in care

172. At the Inquiry’s State Institutional Response Hearing, Acting Chief Executive of Whaikaha – Ministry of Disabled People Geraldine Woods observed that: “we have heard of institutions which did not adequately care and provide adequate care and oversight for individuals.”[217] The ultimate consequence of neglectful care and oversight is death. Over a four-year period in the late 1990s, three adults choked to death at the Kimberley Centre.[218]

173. In 1998, a long-term Kimberley Centre member with a learning disability died after choking on her vomit.[219] She had been seen by staff moments before eating a cake.[220] Staff knew she had difficulty eating and that she had choked on food previously.[221] Despite this, her notes did not include instructions for controlling her behaviour around food or for preventing choking.[222]

174. This person’s death was the second of three choking deaths at the Kimberley Centre referred to the coroner within a two-year period.[223] The coroner recommended that an expert opinion should be sought on the type of food offered to individuals under the care of Kimberley and what other measures should be taken to prevent further deaths from choking. The coroner also commented on the unacceptable delay in assistance arriving, made worse by the delay in getting the resuscitation machine working. The coroner recommended an overhaul of emergency response facilities within the Kimberley Centre.[224]

175. Six months later, in 1999, another person died after choking on a bun that had been left out by staff.[225] This person had a known eating disorder. The coroner found that his death was preventable; he was unsupervised at the time and able to go into a staff smoking area where the buns had been left out. The coroner was concerned at the amount of unsupervised time there was for children, young people, and adults in Kimberley care. These types of buns had previously been provided to residents despite another individual having choked to death on an iced bun.[226] The coroner found that the buns should not have been on the unit, or if they were on the unit, they should have been inaccessible to anyone who could not eat them safely.[227] The coroner criticised the Kimberley Centre’s internal inquiry that immediately followed this person’s death. That inquiry failed to ascertain how he got the iced buns despite this being known to several staff members. The coroner described the internal inquiry as a “very definite cover-up attempt”.[228]