326. The purpose of this chapter is to provide a deeper understanding of the specific experiences of abuse within each setting. Most forms of abuse were present in all settings, particularly psychological, physical, sexual and cultural abuse.

327. The environments and most pervasive and unique forms of abuse and neglect in social welfare settings, faith-based settings, and disability and mental health settings are expanded on below.

Te tūkinotanga i roto i ngā whakaritenga tokoora
Abuse in social welfare settings

328. Social welfare settings include foster care, family home foster care, social welfare residences, youth justice institutions (including borstals), and third-party care providers. As previously discussed, most children and young people entered social welfare settings through children’s courts, after being charged with an offence or for not being under proper control by a parent. A smaller number of children and young people entered into social welfare care following social workers’ notifications of abuse or neglect at home or through voluntary agreement with parents. Many children and young people were considered by the social welfare system or NZ Police to be delinquents in need of control and order, despite some not having committed crimes. Tamariki and rangatahi Māori were disproportionately placed into social welfare settings and made up the majority of the population.

329. Many survivors had existing trauma, were neuro-diverse or experienced mental distress, and this presented as behavioural issues. Children and young people were regularly dehumanised, degraded and treated as criminals. Survivors were subjected to all forms of abuse and neglect in social welfare settings that were often environments of violence, fear, abuse, and neglect.

330. As well as moving between social welfare settings, many survivors experienced a combination of social welfare, faith-based and disability or mental health care settings.

Ngā kāinga maha i te pūnaha tokoora
Multiple placements across social welfare settings

331. Repeatedly removing children and young people and placing them in new care settings, out of home, was traumatic for them. While some foster placements were both necessary and successful for children and young people, continuous upheaval often resulted in survivors’ psychological and neurological development being neglected. In addition, repeatedly removing and placing tamariki and rangatahi Māori could sever any connections they could have had to their whānau, community, and cultural identity.

332. Survivors who experienced multiple placements explained how new environments could disrupt their relationships, lifestyle and education. Survivors also described the loss, grief and anxiety they felt when leaving a placement where they may have felt safe and settled. NZ European Survivor Ms EF shared her experience after having multiple foster and institutional placements from when she was 9 years old in the late 1960s:

“When you go through 20 changes in your young life, living in different homes, you can’t tell me that you’ll be the person who you could have been. I never knew in advance where I was going to go. When I arrived somewhere, I never knew how long I was going to stay there. Even now, packing a bag to go away still brings up that anxiety. Every home you go in you do things differently, and it changes from one home to another ... I would need to watch and learn to figure out how to slot into their life.”[424]

333. Expert witness Dr Sarah Calvert explained that at each placement disruption, there is a further loss that causes the child to experience grief again. This compounding grief can cause a child to “fear the pain associated with potential relationship loss and choose simply to avoid deeper human connectedness”.[425]

334. For some survivors, withdrawing from caregivers was a way to protect themselves, which could become a reason for social workers to move them again. NZ European Survivor Ms ED described her experience in social welfare and youth justice residential care throughout the 1970s and 1980s, from age 18 months to 19 years old:

“I have had my files for quite a long time, so I have spent a lot of years processing and reading between the lines. From what I can gather, a number of placements broke down for the simple fact that I was unable to form a bond with the parents and they struggled with that.”[426]

335. The Inquiry heard that survivors were frequently shifted between social welfare settings’ placements due to resource constraints and overcrowding within social welfare facilities,[427] and perceived behavioural problems.[428] Consideration was rarely given to the behaviour children and young people were exhibiting could be a result of abuse they were experiencing in social welfare settings, or trauma from being moved so often.[429] Many survivors told the Inquiry they felt blamed for their social welfare settings’ placement breakdowns. Many survivors said that no one ever asked or listened to why they were behaving in such ways.[430] Even if they did complain, it was seen as safer to move them out of that care, rather than move the alleged abuser, who often remained.[431] Children and young people would routinely be silenced and moved again.

336. Some survivors described being separated from their siblings when entering social welfare settings. NZ European survivor Ms BA was placed in care when she was 7 years old. She shared how she was repeatedly moved between placements in the 1970s after her existing trauma from her father’s sexual abuse was not addressed:

“I was put into several family homes and foster homes. I think I had a few issues at the time, including that I didn’t trust men. When I was about 7, my foster father at the time came home from work and gave me a hug. I attacked him. No one could understand why. Everyone thought it was because I had a behavioural problem, but it was because I had no trust in males, because of the sexual abuse. No one picked this up when something could have been done to help me. I was shifted from place to place. I would come home from school and a social worker would be there to tell me they were moving me.”[432]

337. Māori survivor Dallas Pickering felt she was blamed when her foster placements broke down. She told the Inquiry that she spent her childhood and teenage years being shifted from one foster home to another:

“I was shifted 12 times by the time I was 15 … I was removed from that foster home because of my behaviour. There were always comments and labels like, you’re naughty, you’re bad, you’ve got a chip on your shoulder. Nobody ever asked me why I was behaving in this way? I did behave badly, I got into fights at school, I was aggressive. My bad behaviour was always the focus. Nobody focused on how to help me deal with the trauma and abuse I had suffered.”[433]

338. Dallas was placed with a family that could have been her ‘forever home’ had they been given the support that they asked for. This family included her in their family photos, celebrated her birthdays and took her on family holidays. However, her social worker’s attitude towards her behaviour meant they made a reactive decision that led to further abuse:

“It felt like normal family life. My foster mother asked for a short break from me, due to my challenging behaviour. She requested counselling to assist me with my behaviour. When she asked to have me back again, she was told I was not coming back. Instead of providing counselling to assist and support my foster family and me, the State decided to remove me from this foster home … I had built a secure attachment to that family and that was severed by the State.”[434]

Te tūkinotanga me te whakahapa i ngā kāinga taurima tamariki me ngā kāinga whānau hoki
Abuse and neglect in foster care and family homes

339. Foster care and State-operated family homes represent the settings where children and young people in social welfare settings were most often placed.[435] While some survivors had positive experiences in some foster homes and State-operated family homes, some were environments where abuse and neglect occurred, with many children isolated from any external support.

340. Foster parents had control over the lives of children and young people within their home. Some survivors described how their foster caregivers were adept at “putting on a show” to hide any signs of abuse or neglect when social workers visited. Māori survivor P Wilde (Ngāpuhi) described how in one foster placement, she and other foster children would be dressed in their best clothes and told what to say when the social workers arrived. “[We] were then ‘presented’ to the social workers who were never allowed to speak with us alone.”[436]

341. Survivors told the Inquiry they felt trapped in what they described as violent and fearful environments. Many talked about experiencing regular beatings, sexual abuse and rape from caregivers as well as from caregiver’s children or foster siblings. Some children and young people were forced to work, or lived in conditions of severe neglect.

342. Survivors who ran away from their foster homes to escape abuse would often be returned to their caregivers without being asked why they had run away. This reflected negative institutional and societal attitudes towards children. NZ European survivor Ms VQ, who had experienced abuse in foster care, explained that although she and other foster children had tried to run away from a foster home, they were never listened to when they tried to explain what was happening in the foster home:

“It is crazy to think that us and others were running away because we were scared and feared for our safety, only to be put back into a situation where the caregiver would be angrier.”[437]

Te whakahapa me te kaiponu kai, marumaru, kākahu hoki i te kāinga taurima tamariki
Neglect and withholding of food, shelter and clothing in foster care

343. Foster care survivors regularly described how their basic needs were neglected through the denial of adequate food, shelter, or clothing. Māori survivor Ms AJ (Tainui) told the Inquiry that it was not a priority to ensure she ate. “I remember having to sit at the table and eat mouldy sandwiches for dinner.”[438]

344. The Inquiry heard of many caregivers withholding or failing to provide appropriate food and drink. This led some children to scavenge in bins, steal food and drink toilet water. Survivor Ms ED said her foster mother withheld food from her for days, before she was force fed and made to eat her own vomit.[439]

345. The Inquiry heard how some foster caregivers neglected to provide, or intentionally withheld, appropriate sleeping conditions and shelter. Survivor Ernest Seadon said he was made to sleep with the foster family’s pet cats, where the cats would “poo and widdle”.[440] NZ European survivor Mr EH described how he was made to sleep outside in a shed despite there being a room inside he could sleep in. When describing the conditions, he said “I had no light out there and I only had the outside toilet ... I wasn’t allowed to sit down in the sitting room by the fire or anything.”[441]

346. The State provided assistance grants for clothes and bedding, with caregivers required to ensure clothing was “kept in good order”.[442] Some foster carers would keep this money for themselves.[443] Māori survivor Gina Sammons (Ngāti Kura) and her siblings described being given second-hand clothes and not often having the correct school uniform or enough clothes in winter, despite finding out that “CYFS [Child, Youth and Family Services] was paying our foster parents board and clothing allowances and other costs that were supposed to be spent on us.”[444]

Te tūkinotanga ā-hinengaro, ā-kaikiri hoki i ngā kāinga taurima tamariki, kāinga whānau hoki
Psychological and racial abuse in foster care and family homes

347. Children and young people were threatened, manipulated, isolated, humiliated and verbally abused. Survivors described being trapped with foster caregivers who would torment them. Some survivors were treated as animals and many survivors in foster care and State-operated family homes were made to feel worthless or powerless.

348. NZ European, survivor Ms M shared her and her sister’s experience over five years in the late 1960s of repeated rape, physical abuse, taunts and terrorising from their foster father. He ‘decorated’ homemade pies with his teeth, wrapped her severed pet lamb’s tail as a Christmas present, would abuse and humiliate his wife including tearing her clothes off in front of the sisters, and threatened the sisters with a loaded shotgun:

“Have you ever heard a crayfish scream as it’s put into boiling water? I was terrified and then later, when I went to bed there was a live crayfish in it ... I realised that he wanted us to cry and so I learnt not to.”[445]

Te whakaiti me te takahi
Degrading and demeaning treatment

350. Many survivors were degraded and treated like animals by foster parents. Survivor Leoni McInroe was frequently made to sleep on the washhouse floor with the dog and eat alone.[449] English survivor Malcolm Axcell also described being treated like a dog in the 1950s: “I was never allowed to eat with [my foster parents]. They used to put my meals on the step outside the back door, and if I didn’t get there before the dog got there, I didn’t have anything to eat.[450]

351. Māori survivor Mr EC (Ngāti Kuri, Ngāti Maniopoto, Ngāpuhi, Tainui) shared with the Inquiry how his foster father buried him in a pit where they would dispose of rubbish such as eel guts and dog mess. He described being buried overnight with only his head exposed, where he was ‘pissed on’ by the family dog, and the dog started ‘having sex’ with his head while people laughed.[451]

352. Several foster care survivors described being wrongly blamed by foster parents for incidents. In some instances, foster parents lied to NZ Police or social workers about the foster child to intentionally show them in a bad light or get them in trouble.[452] Mr EC told the Inquiry he was constantly “blamed for everything … I was the ugly little boy so you blame him. That’s life, mate.”[453]

Te tūkinotanga ā-kaikiri i roto i te kāinga pūnaha taurima tamariki
Racist abuse in foster care

353. Racism could play a part in survivors experiencing differential treatment. Māori survivor Neta Kerepeti (Te Rarawa, Ngāpuhi, Ngāti Wai, Ngāti Mutunga) described being treated differently when placed in a State-operated family home:

“We were only given water or cocoa to drink whereas the others would be given Horlicks and Milo. Whenever new people would come into the house, we always had to double bunk but [the Pākehā girl] had a room to herself.”[454]

354. Some survivors were demeaned because of their ethnicity. Māori survivor Kath Coster (Ngāi Tahu, Ngāti Apa, Ngāti Kuia, Rangitāne) experienced racism in multiple foster homes. At one foster home, the foster family were fixated on the colour of her skin and saw her brownness and whakapapa Māori as ‘dirty’. In one instance, she overheard her foster mother saying she wanted to bleach her skin, and that she believed Māori “belong on the streets.”[455]

355. Māori survivor Hemi McCallum (Ngāi Tahu, Ngāpuhi) experienced racist verbal abuse from his foster father: “He would call me the C word, or ‘black ass’. Not being called my name added to the feeling of being worthless.”[456]

Te whakawehe i te whānau, te tuakiri me te ahurea
Separation from whānau, identity, and culture

356. Some foster caregivers actively tried to separate foster children from their biological whānau. This could be in the form of obstructing communication, preventing physical contact such as visits home or deliberate actions such as destroying gifts from whānau.[457] Māori survivor Ms AJ (Tainui) was prevented from talking to whānau by her foster mother, who would threaten her and her siblings into staying silent when her father visited the home. She said her father would sit outside calling for them while they had to stay inside pretending not to hear him.[458]

357. This disconnection from identity was further amplified by the physical separation many survivors had from their whānau, friends and community. For many, a foster placement involved being geographically isolated from any support they could have had, making it difficult or impossible for whānau to visit their children and young people in care.[459] Isolation and separation also made it harder for children and young people in care to return to whānau after leaving care.

358. The Inquiry heard of many survivors being placed into foster care that did not support their connection to their cultural identity. Māori survivor Hone Tipene (Ngāpuhi) described how, when he went into care he chose to not speak much te reo Māori to certain people: “In some places, the caregivers told us not to use te reo because they couldn’t understand us and thought we were plotting something.”[460]

359. The Inquiry heard from many Māori survivors who went through foster homes that the one of the biggest tūkino – abuse, harm and trauma – for them was the ‘loss’ of whakapapa. Māori survivor Glenda Maihi (Ngāti Pikiao) explained this loss meant she grew up to be a lost soul, not knowing who she was and where she came from: “One of the worst effects of being in State care has been the loss of my identity, my whānau and the loss of my whakapapa … I wanted to know, [why] there was no work by Social Welfare to retain my whakapapa.”[461]

360. Māori and Samoan survivor Jenni Tupu (Ngāpuhi, Ngāti Hine) was adopted at 3 months old and lost her identity through foster care and adoption. She told the Inquiry she does not hold any knowledge of her true whakapapa or cultural identity and is searching for her links and connection.[462] Māori siblings Mr AI and Ms AG (Waikato-Tainui) went into care aged 6 and 4 years old.[463] Ms AG described how being in foster care impacted her knowledge and connection to her whakapapa:

“I have learnt all the words to my mihi, but I don’t feel connected to them, and I don’t feel connected to the places in it. Some of those places I have never been to, or don’t remember.”[464]

He wā tōna ka noho te kāinga taurima tamariki me ngā kāinga whānau hei taiao kaikoka tinana
Foster care and family homes could be an environment of physical violence

361. Survivors told the Inquiry about a range of experiences in foster care where violence was used as a form of punishment or means of intimidation. Children and young people were beaten, left bruised and injured, and hospitalised at the hands of their foster caregivers. Many survivors spoke about receiving ‘hidings’, ‘beatings’, and extreme forms of violence.[465] Often physical abuse came out of nowhere, adding to a child or young person’s fear For many in care, physical abuse was part of daily life.

362. Some caregivers used weapons against foster children, including everyday household items. The Inquiry heard of children and young people being beaten with vacuum cleaner poles,[466] jug cords,[467] leather belts,[468] irons,[469] wooden spoons,[470] walking canes,[471] and sticks.[472] Some survivors also shared how they were deliberately burnt or branded by a foster parent.[473]

363. Māori survivor Tania Kinita (Ngāti Hineuru, Ngāi Tahu, Te Arawa and Ngāiti Whakaue) described how her foster father subjected her to extreme violence: “He knocked me out, pummelled my face black and blue, cracked my cheek bones, broke my nose, sprayed my blood up the walls and kicked me senseless.”[474]

Te tūkinotanga ā-tinana hei aupēhi, hei whakawhiu
Physical abuse to control and punish

364. Some foster parents used violence to discipline or punish those in their care. Several survivors told the Inquiry they were hit or beaten to ‘teach them a lesson’ for alleged bad behaviour, such as stealing. Violence from caregivers could be a response to behaviour outside of the child’s control, including wetting the bed, being sick, or having nightmares. Being physically abused as a punishment for wetting the bed was a common experience shared by survivors of foster care as well as other social welfare settings.[475]

365. Foster care survivor Stephen Shaw shared how he was given ‘hidings’ for waking his caregivers when he had nightmares.[476] He described a foster placement where he was beaten so badly his jaw could have been broken, because he threw up while playing on a swing.[477]

366. Many survivors told the Inquiry they were violently abused for running away from foster homes or attempting to report abuse, including some survivors who were beaten and choked.[478] Survivor Mr FQ said he was forced to pick up thistles and punched and kicked by his foster father because he ran away.[479]

367. Māori Survivor John Heke (Tainui, Maniapoto) said that his foster parents physically abused him and his brother as punishment, including giving them hidings for arriving home late from school or lying:

“To punish me, they put my fingers in the car door and they slammed the door on my fingers with the result of losing all my fingernails. I’ve already got a missing finger and so they picked on that hand … and it was like, ‘Good job, that’s what happens when you steal’.”[480]

Te tūkino aropā
Peer-on-peer abuse

368. Survivors who spent time in foster care were also at risk of physical, sexual and psychological abuse from their caregivers’ biological children or other foster siblings. Some recalled feeling unable to report abuse while in foster care from biological children because they were unlikely to be believed by the abuser’s parents or could be threatened with further abuse.

369. Ms AG shared her experience of being beaten by her caregiver’s children at one of many foster placements during the 1990s and 2000s:

“I think I was about 12 at this stage, and they were all older than me. The daughters were going to the same school as me, so there was no reprieve from their abuse … If I complained to their mum, instead of telling them off, she would encourage them to taunt me more.”[481]

370. Several foster care survivors shared how caregivers would use other children or young people to punish them. NZ European Survivor Mr EH told the Inquiry about a foster placement he had at seven years old, where he was regularly physically abused by his caregiver’s biological son who was also seven:

“[If] I did something wrong then [my foster father] would get us in the shed, boxing gloves on, and hold me for his son to punch me. I used to try and punch back but I couldn’t. I was only a small boy.”[482]

371. Some foster placements also involved the risk of sexual abuse from other foster children.[483] NZ European Survivor Mr HK was sexually abused when sharing a bunk bed with a foster sibling at a State-operated family home in the early 1980s. He was made to get in the top bunk and masturbate the sibling, who would do the same to him. “He’d use some sort of round wooden thing ... and insert it into my anus.”[484]

Te taitōkai i roto i te kāinga taurima tamariki me ngā kāinga whānau
Sexual abuse in foster care and family homes

372. In foster and State-operated family homes, survivors were subjected to grooming, inappropriate touching, sexual assault and rape and forced to perform sexual acts on others. Some survivors found they would be ignored, disbelieved or at risk of further abuse when reporting to one foster parent that they were abused by the other.[485]

373. The private nature of foster homes, and the power caregivers had over their lives, meant children and young people were particularly exposed to the risk of being sexually abused. The Inquiry regularly heard how foster caregiver abusers would manipulate and take advantage of those in their care to both enable and conceal abuse. Some survivors were as young as five years old when a caregiver began to groom, rape or molest them.[486]

374. Some survivors shared how the dynamics of ‘family’ were used to manipulate, groom, and sexually abuse them. One survivor who was raped by his foster mother from 11 years old shared that if he wanted anything, he would have to have sex with her.[487]

375. NZ European survivor Andrea Richmond entered foster care when she was 10 years old. She described how her foster father groomed her through touching her in a way that seemed innocent at first by ‘play fighting’ with her. She said this was a test to see how she responded: “I joined the play fighting because I wanted to be part of the family ... [This] happened a couple of times, then it moved to full sexual abuse, he would have full sex with me.”[488]

376. Multiple survivors gave evidence of being sexually abused in their beds by foster parents and other children, including their caregiver’s biological children. Survivor Ms EM described how the foster father who molested and raped her and others “would use the same line with all the girls by saying that he was coming to tuck us in”.[489]

377. Survivor Dallas Pickering, who was in foster care during the 1970s and 1980s, stated it “became the norm” to be abused by other children in the foster home:

“Older kids would come into my bedroom at night and sexually abuse me. I did not feel safe at all. There was no supervision. There are no records of my time at this [State-operated] family group home. The caregiver was not supervised, and neither was I.”[490]

378. Survivors told the Inquiry of caregivers forcing them to perform sexual acts with other children against their will. Pākehā, Māori survivor Mr FZ (Tainui Maniapoto) said that his foster parents forced him to do sexual acts with a young girl in the home.[491] Survivor Vincent Hogg told the Inquiry he and two other young girls were sexually abused by their foster father, who would touch the three of them and encourage them to touch each other.[492]

379. Some survivors who went through foster care described being abused by non-caregiving adults who were given access to them. Māori survivor GH, who is non-binary, shared that they and their brother were abused by the male colleague their mother used for respite care:

“He would make us jack him off and perform sexual favours including making [my brother] ejaculate him. He would also rub his private parts all over me. This happened every weekend that we were left in his care.”[493]

380. For some survivors, their experience of foster care included abuse from the social workers who were supposed to keep them safe. One survivor who went into care as a baby shared how a social worker groomed and molested him throughout many placements in the 1960s. He recalled being moved to over 100 different homes: “The minute someone got close to what was going on to ask [the social worker] questions, I’d be moved again.”[494]

Te whakahāwinitanga o ngā tamariki me ngā rangatahi i roto i te kāinga taurima tamariki
Children and young people exploited for labour in foster care

381. Many foster care survivors described being exploited for their labour,[495] and some worked in conditions they described as slavery.[496] The Inquiry heard about exploitation on farms, with overwhelming chores or duties, and when providing care for others. Many survivors missed out on education or other important parts of their development.

382. What is considered appropriate work for children has changed over time, but many accounts go beyond any accepted standard of children’s work in Aotearoa New Zealand. Children and young people were regularly withheld from schooling against their wishes in order to work for the benefit of their foster caregivers. Ms EJ shared, “I worked while I was [in foster care]. I was their free labourer. I wasn’t allowed to go to school, even though I wanted to go to school.”[497]

383. Some survivors felt they were exploited for work and household duties by their foster caregivers. Several survivors on rural foster placements described having to do excessive farm work from a young age.[498] Survivor Mr EH described what he had to do before school on one of the farms he was forced to work on as a 12-year-old in the 1950s:

“I’d have to go and milk the cows by hand. Put the cream out, feed the pigs, have breakfast, get ready, and then go to school. It was the same thing at night again.”[499]

384. The Inquiry also heard how the labour exploitation of children and young people could occur alongside racism. Samoan and Māori survivor Jenni Tupu (Ngāpuhi, Ngāti Hine) described how her Pālagi and South African foster parents would make her and other foster tamariki Māori work on their farm while their biological children went to school. She told the Inquiry: “I remember being made to do lots of work on the farm and I have memories of often being hungry and being referred to as a ‘little brown darky’.”[500]

Te Hōtaka Tamariki Manene me te whakahāwinitanga
The Child Migrant Programme and labour exploitation

385. The Inquiry heard how labour exploitation in foster placements took place in the Child Migrant Programme. From 1947 to 1954, 549 children and young people were taken from their families in the UK and sent to Aotearoa New Zealand alone.[501] Many had to carry out intensive and unpaid farm work at rural foster placements.[502] Survivor Leslie Pritchard described being sent to Aotearoa New Zealand as a child migrant:

“It was all supposed to be a new beginning in a land of opportunity. Nobody told me I’d be sent to the middle of nowhere, clearly just a source of unpaid labour.”[503]

386. The programme had labour at its heart [504] and children and young people were placed with families on an employment basis.[505] Custody records showed placements with ‘employers’ and opportunities to learn farm work.[506] For many survivors, the reality meant carrying out hazardous and intensive labour at the expense of their child/teenage-hood and education.

387. These children and young people were entitled to wages and their caregivers had further employment obligations.[507] Despite this, many survivors were never paid and some experienced physical and sexual abuse while labouring.[508]

388. English survivor Malcolm Axcell was placed into an Aotearoa New Zealand foster home through the programme in the 1950s. He told the Inquiry that children as young as five years old were made to work on the farm for free, and that he was treated “like a slave”. At 15 years old, Malcolm was taken from school to work on the farm every day. He was beaten with a strap by his social worker whenever he tried to raise any issues with his placement.[509]

389. Survivors of the Child Migrant Programme in Aotearoa New Zealand shared how their exploitation for work purposes exposed them to the risk of further physical, sexual or psychological abuse and meant their education and development were neglected. Overseas inquiries into child sexual abuse found that many of the survivors of the Child Migrant Programme were abused and exploited,[510] leading the Australian government to make formal an apology on 16 November 2009.[511] In the same year the former Social Development and Employment Minister, Hon Paula Bennett, considered the treatment of child immigrants who were part of the Migrant Programme was better than what had occurred in other countries and despite then British Prime Minister Gordon Brown announcing that he would make a formal apology for Britain’s role in the Child Migrant Programme.[512] No State apology to survivors of the Child Migrant Programme has been made in Aotearoa New Zealand.[513]

Te tūkinotanga me te whakahapa i ngā wāhi tokoora
Abuse and neglect in social welfare institutions

390. The term ‘social welfare institutions’ is used at times throughout this report. There was often no distinction made by survivors between social welfare residences that catered for children and young people with ‘care and protection’ needs where it had been determined by a social worker or the courts that they required out-of-whānau care and support; and youth justice residences that catered for children and young people placed there bv the courts as a result of youth justice charges. In addition, these facilities and their environments shared many similarities including that they tended to be isolated from mainstream communities, sometimes located in remote places, segregating the children and young people in them from society even further. Although the term ‘residences’ suggests a homely environment of warmth and love, the reality for those survivors living in these types of facilities was the opposite

391. During the Inquiry period, some social welfare facilities functioned as both social welfare residences (known from 1989 as ‘care and protection’ residences)[514] as well as youth justice residences/institutions that were run at the time by the Department of Justice. This meant that the facility housed:

a) Some children and young people with ‘care and protection’ needs; and
b) Some children and young people that were placed in the facility bv the courts as a result of youth justice charges.

392. Survivors described social welfare institutions as hierarchical environments where some staff and residents would regularly take advantage of those younger or ‘weaker’.[515] Institutional life centred on control and discipline, often through extremely abusive means.[516] The process by which children and young people lose their identity and independence through spending time in an institution is known as institutionalisation.

393. The institutionalisation of children and young people was not only an impact of being placed in social welfare institutions, but also a deliberate strategy to address perceived delinquency. Children and young people considered too difficult, old, or ‘unsocialised’ for foster care would often be placed in social welfare institutions to fix their behaviour.[517] The State favoured highly regimented and controlled environments over whānau or foster placements for supposed delinquents.[518]

394. In some instances, social worker’s reports recommended placement in a social welfare residence or youth justice institution,[519] to remove the child from the influence of their whānau, or because they were a ‘lost cause’ destined for a criminal or psychiatric institution.[520] Institutionalisation of residents began with the depersonalised and traumatic admissions process and continued day to day.

395. The institutionalisation process often separated children from their identity (in some cases, deliberately), including cultural identity, family, wider whānau and support network. Most larger social welfare institutions were national institutions, which meant that children and young people were placed in them from across the country.[521] This made regular visits from whānau extremely difficult and isolated those in care. These children and young people were fully reliant on the social welfare institution and its staff to meet their emotional and developmental needs. In these institutions the delivery of care and protection was often inadequate. This could manifest with children and young people experiencing:

a) delays in their emotional, cognitive and physical development with a heightened risk of developing behaviours and becoming a victim of emotional, physical and sexual abuse;
b) a regimented routine, which resulted in the children and young people following a prescribed daily schedule with little flexibility with limited encouragement or support to develop and show their personal preferences and individuality.

396. A disproportionate number of children and young people being admitted to social welfare institutions were Māori and Pacific, and in many social welfare institutions, tamariki and rangatahi Māori made up the majority of the residents. Not only were tamariki and rangatahi Māori and Pacific children and young people subjected to racist abuse in social welfare institutions, there were no processes in place to positively acknowledge their identity or ensure they were able to practice or maintain their culture. Samoan survivor David Williams (aka John Williams) shared that “No one asked me officially what ethnicity I was when I arrived. But they knew who was a Māori and who was a Pacific Islander. They never acknowledged our culture or ethnicity in a positive sense”.[522]

397. Institutional life was an unsuitable and inherently abusive environment for children and young people, that failed to meet their needs. The Inquiry heard from many survivors and staff about the embedded culture of violence in social welfare institutions, how abuse was so prevalent it was to be expected, and how staff encouraged or condoned violence.

398. Survivors described social welfare institutions as feeling like prisons and reported being treated as criminals. This was reinforced by dehumanising experiences including strip searches, neglect of basic needs, and solitary confinement in secure units or ‘cells’.[523]

Te whakaiti i te urunga atu
Degrading treatment upon entry

399. Many survivors described how frightening, confusing, and traumatic entering social welfare institutions could be. For some survivors, entry into care was the beginning of the worst time in their lives. One described Allendale Girls’ Home in Tāmaki Makaurau Auckland as a “soul destroying” place for many girls, and how living there “broke people’s spirit”.[524]

400. Survivors’ impressions when entering social welfare institutions were characterised by dehumanising treatment,[525] a suppression of individual identity,[526] intimidating behaviour, and failure to identify and respond to individual children’s needs. The transfer and arrival processes were often an introduction for survivors to abuse and the invasion of their privacy and bodies. Communication about what was happening to them and why completely lacked transparency and many survivors were lied to by the State.[527]

401. Children and young people were stripped of clothing and possessions on arrival and subjected to invasive practices such as forced strip searches,[528] and being showered in “nasty chemicals”.[529] Pākehā Māori survivor Rawiri (David) Geddes (Ngāpuhi) described arriving at Ōwairaka Boys’ Home in Tāmaki Makaurau Auckland in 1981:

“The first thing they made you do on arrival, and I felt very belittled by this, was to strip you down to nothing.”[530]

402. Youth justice institution residents were also subjected to invasive strip searches. One resident said in 1998 that she had to strip in front of a staff member and spread her legs with no other staff present.[531] Samoan survivor Mr GU described how in such an instance he could hear staff laughing and realised that they were making him “bend over naked, multiple times, just for their own amusement.”[532]

403. The routine practice in State institutions of immediately placing children and young people into solitary confinement is discussed later in this section, along with ‘initiation’ beatings by other residents.

Te arotake puapua manioro
Invasive vaginal examinations

404. Some girls and young women were subjected to vaginal examinations to test for sexually transmitted infections on their admission to social welfare institutions. Girls and young women would lie on a bed, naked from the waist down, usually with their legs placed in stirrups.[533] They were often held down by staff or strapped to the bed so they could not move.[534]

405. Some survivors described to the Inquiry how these invasive vaginal examinations were routinely performed without explanation or consent, which denied their bodily autonomy and only added to the trauma of the examinations. Vaginal examinations represented physical, sexual, psychological, and cultural abuse for many survivors.

"Those examinations told me that adults had rights to my body, no matter who they were. That is wrong. It is so wrong to get that idea in your head as a child, because as a woman, your value for yourself is lost.”[535]

406. Vaginal examinations were regularly conducted in an uncaring fashion, with survivors made to feel ‘unclean’.[536] Vaginal examinations were undertaken on the assumption that girls in care were promiscuous and infected with diseases, even in cases where girls and young women stated they were not yet sexually active, they were often not believed and still required to undergo an examination.[537] These examinations instilled a sense of shame in girls and young women around their assumed promiscuity and were based on sexist and misogynistic assumptions of girls and women in care.

407. Examinations could be even more frightening for survivors with a history of rape or abuse. Some shared how despite being a child or young person, staff would never investigate why their examination indicated they were not a virgin.[538] Many survivors were so traumatised by these vaginal examinations that they tried to shut out those memories in later life.

408. Abusers also used vaginal examinations as an opportunity to sexually abuse girls and young women. Māori survivor Gwyneth Beard (Ngāti Porou) described getting an abusive examination from Dr Morgan Fahey on returning to Strathmore Girls’ (Ferry Road) Home in 1977, a doctor who was later convicted for similar sexual offending against multiple women:

“When I look back to the way Dr Fahey took swabs, I understand what was going on. He was touching parts of my body down there that he should not have been. Looking back, I know it was wrong.”[539]

409. Survivors also told the Inquiry they could be placed in solitary confinement as punishment for refusing to consent to vaginal examinations,[540] despite social work guidance from 1975 onwards, stating that examinations were only to be pursued for ‘at risk’ girls and young women.[541]

410. For Māori survivors, this tūkino – abuse, harm and trauma – was a transgression against the tapu of their body, particularly that of whare tangata.

Te tūkinotanga ā-hinengaro, ā-ahurea anō hoki
Psychological and cultural abuse

411. Psychological abuse was experienced by all survivors who spoke to the Inquiry about their time in social welfare institutions. At a system level, these institutions were inherently abusive and inappropriate environments for children and young people, cutting them off from whānau and failing to provide them with the support and nurturing they needed.

412. Bullying and verbal and emotional abuse by staff at an individual level was entrenched and widespread across all social welfare institutions. Bullying by other residents went unchecked or was encouraged. Many survivors told the Inquiry of being constantly put down and told they were useless,[542] stupid and made to “feel bad and degraded”.[543] Survivors were told as children or young people that no one loved or wanted them, that they were a “worthless piece of shit”, and that they would amount to nothing.[544]

413. Many children and young people in social welfare institutions were told they were destined for a life in prison or psychiatric care. Some survivors were told that they were “born criminals”. NZ European survivor Michael Rush told the Inquiry that he and other social welfare settings’ residents were conditioned to think they were criminals who would go to prison:

“If you keep telling someone they are going to end up in prison, sooner or later they will believe you and that’s what will happen.”[545]

414. Survivors regularly shared how social welfare institutions were harsh and lacking in aroha, care and affection.[546] Pākehā and Māori survivor, Sharon Byles (Ngāti Tūwharetoa, Ngāti Raukawa, Ngāti Hineuru, Ngāti Uenuku, Ngāti Kahungunu ki Te Wairoa, Ngāti Kahungunu ki-Heretaunga, Ngāti Apa, Ngāti Kahungunu) described the lack of care from staff at Allendale in the 1970s: “You would have a girl in the corner crying, but the staff wouldn’t do anything about it. It’s like they just didn’t care at all.[547]

415. Expert witness Dr Sarah Calvert explained that care institutions cannot provide the opportunity for residents to develop secure attachments with staff, because there is no continuous relationship or sense of belonging.[548] Dr Calvert said the institutional environment, “can lead to difficulties in adjustment and can disrupt healthy development. Care giving institutions simply cannot replicate a “family environment’.”[549]

416. Many residents felt that living in social welfare residences and institutions and conforming to that facility’s systems, often with little or no whānau contact, reduced their mana. Māori survivor Waiana Kotara (Ngāti Hako, Ngāti Maniapoto) spent four years at social welfare institutions in the 1970s. She described the lack of care she experienced:

“[I was placed] in institutions for my ‘care and protection’ but there was nothing caring about being removed from my whānau. There was nothing caring about the staff telling me that my mother was bad because she was involved with gangs. There was no love, no care and no protection. At that time, my mum was not in the gangs. This was the system’s interpretation of my mum.”[550]

417. Many survivors explained how social welfare institutions were strict, regimented, militant, and made them fearful of stepping out of line. Survivor Greg from Ōwairaka, who entered Ōwairaka Boy’s Home in Tāmaki Makaurau Auckland in the mid-1960s when he was 13 years old, described the regimented structure:

“Everything was about discipline and you were shit scared of everything and everyone. There was no compassion or empathy or support shown from staff. You had to do what you were told or there were consequences. It was very regimented and structured – don’t rock the boat.”[551]

418. European survivor Walton Warner described how the bullying and verbal abuse he suffered from staff at Ōwairaka Boy’s Home in the 1950’s was relentless:

“To be constantly bullied and told that I was useless was not a good environment to live in ... It’s hard to articulate, but when you are told that you’re a pig every day, you get used to it. It becomes water off a duck’s back.”[552]

419. NZ European survivor Philip Laws described the emotional and psychological abuse he experienced from staff and peers at Hamilton Boys’ Home as “hell on earth” and “round the clock torture”. He told the Inquiry about the verbal and physical abuse he experienced which was sometimes compounded with racial discrimination: “I remember being told I was useless, scum, a white maggot and a pākehā scumbag. They would push me on the ground and make me crawl. It was degrading.”[553]

420. A shared experience for many survivors was how being in social welfare settings made them lose a part of their identity. Dehumanising practices such as being referred to by a number rather than a name amounted to psychological abuse or neglect for many survivors. The Inquiry received evidence of one resident who detailed some of these practices at Ōwairaka Boys’ Home and Wesleydale Boys’ Home in Tāmaki Makaurau Auckland during the 1970s, including that staff would never use his name, or only use his last name.[554]

421. The erosion of identity and dehumanisation experienced by some survivors in institutional environments amounted to psychological abuse and cultural neglect. Māori and Pacific survivors were effectively disconnected from their language, identities and culture by social welfare settings, sometimes violently. Māori survivor Hohepa Taiaroa (Ngāti Apa, Ngāti Kahungunu) shared that he and others were scolded by Māori staff members at Kohitere Boys' Training Centre in Taitoko Levin if they heard them speaking reo Māori.[555] Māori survivor Mr LT said: “I lost my te reo and my tikanga at Epuni [Boys’ Home] and Kohitere [Boys’ Training Centre]. They beat it out of me.”[556] In this way, Māori survivors experienced whakaiti which was targeted at their Māoritanga.

422. Some survivors also spoke about overt racism they experienced while in social welfare settings. Survivors described to the Inquiry how some from social welfare settings’ staff believed that Māori and Polynesians were inferior intellectually and culturally.[557] Staff members labelled tamariki and rangatahi Māori as ‘dumb’,[558] and belittled Pacific children and young people by speaking ‘pidgin English’ to them.[559] Pacific survivor Fa’amoana Luafutu, shared how boys’ in Ōwairaka Boys’ Home in Tāmaki Makaurau Auckland were told to submit to the authority of white staff because they were smarter than Pacific children and young people and cleverer than tamariki and rangatahi Māori.[560]

Te whakahapa kaikiri, ahurea hoki
Racism and cultural neglect

423. Racial discrimination and cultural neglect were regularly experienced by Māori and Pacific survivors while in social welfare settings.

424. Māori and Pacific language and cultural activities were not perceived as a priority in most social welfare institutions and more broadly across other State settings. Some survivors described being punished for practicing their culture. One survivor described Epuni Boys’ Home and Kohitere Training Centre both in Taitoko Levin in the 1970s:

“There was no acknowledgement of cultural needs in any of the boys’ homes. We were not allowed to speak te reo Māori. There wasn’t anything to do with recognising our cultural identity; that wasn’t encouraged in any way.”[561]

425. Survivors also spoke about being targeted, degraded and abused because of their ethnicity. Māori and Pacific children were often grouped in treatment. Records from social welfare settings, and across many other care settings, would group both as ‘Polynesian’. Māori survivor Loretta Ryder told the Inquiry about her experiences of racism at Bollard Girls’ Home:

“When there were certain staff working, you knew you had to watch your walk and your talk. This happened more when the staff were Pākehā. I didn’t know what racism was when I was growing up but at Bollard, the Pākehā girls got treated a lot better than the Māori girls did.”[562]

Staff members spoke differently to us Māori girls compared to the Pākehā girls. The tone was different, and they used nicknames like honey or love when talking to Pākehā girls, but they didn’t do that with us.[563]

426. Samoan survivor David Williams (aka John Williams) described the racism that he saw and experienced from staff at Ōwairaka Boys’ Home in Tāmaki Makaurau Auckland in the 1970s:

“The racism was another thing. You had the white boys who were treated not too bad. Then you had the Māori who were treated like shit. But then if you were an Islander you were dog shit. They would step all over you. Staff used to tell me nobody wanted me and other things like ‘you’re useless, you should go and kill yourself.’ Don’t get me wrong, the Māori were treated like shit. But if you were underneath that, you were absolutely nothing.”[564]

427. In addition to the targeted abuse towards Māori and Pacific children and young people, there were instances of staff inciting race-based violence. A Pākehā survivor who was a resident of Epuni Boys’ Home in Taitoko Levin described how a staff member provoked an attack against him by telling a group of kids that he had called them niggers.[565]

“And then next minute they’re attacking me. And he would just sit there, like a [salivating spectator of gladiators], watching me fucken [sic] defend myself.”[566]

428. Interviews with former staff indicate they were aware targeted abuse occurred. Accounts from the 1970s included that “white staff” used “humiliation techniques” on tamariki and rangatahi Māori,[567] and “housemasters abused Polynesian boys in [the] dining room”.[568] Despite the efforts of some staff, survivors continually suffered from incidents of targeted racial abuse.

Te whakahapa tinana me te whakaparau i ngā matea matua
Physical neglect and denial of basic needs

429. The Inquiry heard that the neglect of basic needs was a regular experience for survivors in social welfare settings. The Inquiry also heard from survivors who experienced medical neglect, through illness and injuries that went untreated. For some, their neglect was underpinned by negative or dismissive attitudes to children and young people in care[569] and outright racism,[570] ableism and disablism.[571]

430. Staff from social welfare settings sometimes withheld food to punish residents.[572] A former boys’ home head teacher described an ‘off privilege’ system of collective punishment, where no residents received morning tea, afternoon tea, or supper including from the time a child ran away until they were found.[573] Survivor Monique de Latour told the Inquiry that when she was placed in the secure unit at Bollard Girls’ Home in Tāmaki Makaurau Auckland, residents had food withheld when they tried to talk to each other through the air vents.[574]

431. Some survivors slept on the floor in social welfare residences,[575] often because of under-resourcing and overcrowding.[576] Some concerns were raised about sleeping conditions by staff. A 1973 letter from a senior social worker to the Director-General of Social Welfare described Fareham House in Pae-Tū-Mōkai Featherston being in a poor state of repair, including having sagging mattresses with distorted frames.[577]

432. Survivors described how being provided with inappropriate clothing caused sickness and injuries at social welfare residences. Survivor Vernon Sorenson described having to wear jeans during a hike at Kohitere Boys’ Training Centre in Taitoko Levin in the 1970s. “They got all wet and I came down with pneumonia.”[578]

433. Long-term social welfare residences such as Kohitere Boys’ Training Centre in Taitoko Levin and Miramar Girls’ Home in Te Whanganui-ā-Tara Wellington had a focus on vocational training.[579] A key part of this was work programmes, with Kohitere Boys’ Training Centre providing forestry work and other training programmes throughout its history.[580] The Inquiry heard survivors describe work programmes as unsafe environments without appropriate oversight, which could result in serious accidents.

434. Survivor Daniel Rei Mr GO described how children and young people in the forestry programme at Kohitere Boys’ Training Centre in the late 1980s did not receive any training before cutting down trees:

“There were no safety measures or regulations in place. We were given axes and a file ... If you were too slow, some of the older boys behind you would cut the trees on top of you. I was injured on a number of occasions.”[581]

435. Despite this high-risk work environment, NZ European and Māori survivor Peter Brooker (Waitaha) told the Inquiry that he and other boys would “sniff glue and paint while working in the forest ... The forestry bosses sat in their little offices on site, while we ran around the forest high on glue or paint. The staff were aware.”[582]

436. Institutional records confirm that survivors sustained serious injuries during work placements. A 1963 accident report from Kohitere Boys’ Training Centre shows that a 14-year-old boy: “suffered a severe laceration of the back of his arm [when it] came in contact with the blade of a ripsaw machine”.[583] In addition, the 1971 Kohitere Boys’ Training Centre annual report noted that five boys had required surgery, with 20 being admitted to hospital after “a more-than-usual run of minor accidents, the majority in the forestry section”.[584]

437. Survivors also shared how social welfare settings staff neglected their health. Pacific survivor Mr TO described being denied treatment as a punishment at Epuni Boys’ Home in Taitoko Levin in the 1990s: “A medical appointment was made for me. Because I was not doing what I was told during recreation time, staff cancelled my medical appointment. The next day, [a staff member said] that I should have been taken to hospital.”[585]

438. Social welfare settings neglected to properly support and educate survivors who were going through puberty. Māori survivor Gwyneth Beard (Ngāti Porou) described learning about period hygiene in a social welfare girls’ homes, and how she now understands her experience in light of the tapu of her whare tangata:

“No one said, ‘This is what you’re meant to do.’ ... I didn’t understand that a period is what you get ... I’m just really embarrassed about that and I shouldn’t have to be – as Māori women, our bodies are sacred.[586]

He rite tonu te whakamahia, te ākina hoki o te kaikoka ā-tinana
Physical violence was routinely used and encouraged

439. Cruelty, violence and abuse were embedded in the way social welfare settings functioned and were ritualised in survivors’ day-to-day lives. Most survivors who spent time within social welfare institutions such as Hamilton Boys’ Home in Kirikiriroa Hamilton, Kohitere Boys’ Training Centre and Epuni Boys’ Home in Taitoko Levin and Ōwairaka Boys’ Home in Tāmaki Makaurau Auckland discussed the culture of violence within those facilities. Survivors recall physical violence being so common in social welfare institutions that it was unavoidable. Māori survivor Wiremu Waikari (Ngāti Porou) described how violence was everywhere at Epuni Boys’ Home:

“I could feel myself becoming immune to the violence that was all around me ... after I had been at Epuni for a while, when a housemaster kicked me as I walked past him, it did not feel like assault because it did not actually break any bones.”[587]

440. For many survivors, an ‘initiation beating’ soon after they were admitted to the social welfare or youth justice institution would be their introduction to peer-on-peer physical violence. This could include ‘stompings’ ‘blanket bashing’ or being forced to ‘walk the line’ (run between two lines of peers who would each physically abuse the newcomer in turn)[588]. Evidence from former staff supports that they were aware of, or even condoned initiation beatings for new residents at social welfare institutions.

441. Speaking about Ōwairaka Boys’ Home, survivor Mr GA explained: “I was a hard fella. I could take a beating, but I’d never been knocked out before I ended up in that place.”[589] Survivor Mr HO described a violent initiation after entering Ōwairaka Boys’ Home in the 1970s:

“When I arrived at the gym I got my welcome beating. It was the boys who would beat you, but the screws watched it. I did not know this at the time but later learned that it happened to all the boys who came through Ōwairaka.”[590]

442. Former staff, experts, and survivors described social welfare institutions as environments where abuse was part of everyday life. Some survivors recalled staff and residential social workers hitting them with makeshift weapons, such as sticks, a vacuum head, a pool cue and a broom stick. In a statement to NZ Police, a survivor recalled going to hospital after being hit by a house master: “[He] grabbed a hockey stick and used it to smash my right ankle.”[591]

443. Physical abuse was routinely used to control and punish children and young people, with the fear of this violence used to reinforce the power imbalance between staff and residents. Professor Elizabeth Stanley told the Inquiry that physical violence was experienced through cruel or unusual forms of punishment in social welfare residences and institutions, was used to assert control and enforce compliance, and was “endemic”.[592]

444. Punishments could be extremely violent and given for minor behaviour issues, sometimes for things that were outside of children’s control. The Inquiry heard how staff pulled children’s hair, punched, slapped,[593] and kicked them.[594] Survivors described being dragged by staff, wrestled to the ground, thrown into walls, and put into headlocks.

445. Samoan survivor David Williams (aka John Williams), who entered care when he was 9 years old and spent time at Invercargill Borstal Institution for Lads said staff created a culture of fear and violence that was used to control residents and prevent acting out:

“These two guards, they grabbed this other fella and grabbed me by the hair and just dragged us … straight in the cell, and we got … a couple of kicks in the guts for our troubles. But the thing is you didn’t have to do anything, it was just at their amusement. You know, you didn’t have to get into trouble, but that’s how they kept everybody in line.”[595]

446. Social welfare survivors spoke about the harsh physical training and extreme violence they were subjected to, often under the guise of punishment. Māori Survivor William MacDonald told the Inquiry about the violence he experienced at the hands of a housemaster at Epuni Boys’ Home in Taitoko Levin:

“[The housemaster at Epuni] had a bad attitude, he was so aggressive. When we came outside, they used to have lines on the concrete and I didn’t know what these were for. So when I met him on my first day out of secure he came up to me and said, ‘get on the line’. Then he just came up and hit me with a piece of wood on the back of my legs and I fell to the ground. He’d whack you until you had your feet firmly on that line. I also remember him whacking me against a door.”[596]

447. Staff not only physically abused residents themselves, but often encouraged, instigated or organised peer-on-peer abuse. The Inquiry heard staff would often arrange fights between children and young people, usually to punish one of them. Many survivors described a culture where children and young people were expected to resolve issues through violence.[597]

448. Some survivors were placed in situations where they had no option but to fight peers to avoid beatings from staff members.[598] The Inquiry heard how some staff encouraged violence, standing by while residents fought. NZ European Survivor Scott Carr said: “Outside of Epuni [Boys’ Home], violence was considered bad, but inside Epuni it was encouraged.”[599]

449. The Inquiry heard of instances where staff organised physical fights between children and young people in social welfare institutions for their own entertainment. Māori survivor Rawiri (David) Geddes described this occurring at Ōwairaka Boys’ Home:

“We were used by the guards … we were put in boxing rings, told to fight each other, even if the other person didn’t know how to – blood was drawn and it did not stop there.”[600]

450. Some survivors recalled racist abuse accompanying violence. Māori survivor Wiremu Waikari shared how an Epuni Boys’ Home staff member slapped him and called him a ‘bloody little monkey’ as an 11 year old in 1969.[601] Wiremu also described racist violence from staff at Epuni Boys’ Home and how a staff member once picked him up and threw him across the room: “I remember [him] on his knees next to me, punching my head and shoulders, calling me a ‘little black bastard’.”[602]

Te pūnaha pou kīngi
The kingpin system

451. The kingpin system was a type of peer-on-peer abuse common throughout social welfare institutions, where one ‘kingpin’ resident would exercise and maintain control over others through intimidation and physical abuse. The kingpin was usually older, stronger and had defeated other residents in physical fights to attain the title. The kingpin would physically abuse other residents, and recruit peers to assist them with violence. Many settings had some form of hierarchical peer-on-peer abuse but ‘kingpin’ was a specific term used in social welfare institutions.

452. Some staff used the kingpin system as a means of control, forcing children to abuse their peers.[603] Staff would arrange for the kingpin to violently ‘discipline’ residents who misbehaved.[604] In return, staff members provided ‘rewards’ and privileges to the kingpin, such as cigarettes, extra food, or easier chores.[605] Survivor Scott Carr told the Inquiry that instead of disciplining residents themselves, staff members got older and bigger residents to do it: “If I misbehaved, staff members would threaten me with a ‘mean hiding’ from one of the bigger boys.”[606]

453. Kingpins would target residents they perceived as different. Survivor Rawiri (David) Geddes witnessed a kingpin abuse another resident based on their perceived sexuality:

“The kingpin had told everybody this boy was a homosexual and all I remember is the young boy being put on to the ground, held down, and the boys taking the rake and raking it straight down his back.”[607]

I rangiwhāwhāhia te taitōkai, ā, i āta whāia
Sexual abuse was pervasive and often targeted

454. Children and young people in social welfare institutions were subjected to widespread and severe sexual assault and rape by staff, peers and external visitors. For survivors growing up in social welfare institutions, this environment was generally lacking in affection or support from adults. Some abusers used this to their advantage to facilitate grooming by showering survivors with attention and gifts. Grooming would lead to abusers initiating sexual contact, with some abusers falsely claiming they were being caring or loving.

455. Māori survivor Mr GQ was groomed at Kohitere Boys’ Training Centre in the 1980s. He told the Inquiry that at first he thought the staff member was being nice. “Then he started touching my knee and moved on to trying to fondle me. As he did so he would tell me that it was okay and that he was just trying to love me.”[608]

456. It was common for staff abusers in social welfare institutions to intentionally isolate children to enable sexual abuse. The Inquiry heard how survivors were given particular jobs where staff could corner them or were placed into isolation rooms and secluded. Samoan survivor David Williams (aka John Williams) shared how, at Hokio, if you got called into the chef’s kitchen, other residents knew what would happen: “There was nothing we could do for the poor bugger.”[609]

457. Pākehā survivor Gary Climo entered care when he was 11 years old and was a victim of sexual abuse at Epuni Boys’ Home in the 1960s. He recalled how staff abusers would isolate and abuse other boys within the residence:

“There were a hell of a lot of dark corners at Epuni. [A staff member] was getting the boys in the gym and doing it around corner[s]. The staff would come into the showers and do it as well.”[610]

458. Scottish survivor Nellie Boynton entered care when she was 13 years old. She shared with the Inquiry that when a 1970s Kingslea Girls’ Home staff member was alone on the night shift, he would isolate her in a staff room and sexually abuse her. She said “He abused me so frequently that I stopped counting the times. He would identify and pick out the weakest girl in the group.”[611]

459. Rawiri (David) Geddes, a survivor who went through Ōwairaka Boys’ Home during the 1970s spoke about how sexual abuse from staff was common. He described boys going missing at movie nights:

“We knew where they had gone, they had been picked out by the guards to be sexually abused. When an abused boy came back in you could tell what had happened. They would have their heads down, tears streaming down their face.”[612]

460. Many survivors spoke about staff in social welfare institutions targeting children or young people they believed to be weak. Some staff abusers watched initiation beatings to identify targets for sexual abuse. Māori survivor Mr SN described how staff members at Holdsworth School in 1972 knew about the initiation process and some watched it:

“When I was young, I did not realise that those staff members were watching us to see which boys were weak. If you were weak, staff would regard you as a person that they could manipulate and eventually abuse.”[613]

461. Interviews with staff from Weymouth Girls’ Home in Te Tonga o Tāmaki Makaurau South Auckland and Ōwairaka Boys’ Home in the late 1970s showed awareness of targeted abuse towards survivors.[614] Samoan survivor David Williams (aka John Williams) recalled racist abuse during sexual assaults by staff in the 1970s. He said: “When I was being raped … I was told ‘this is all you’re good for, you’re a coconut, you are the lowest of the low, you are just a piece of shit’.”[615] This was an example of co-occurring abuse that was specifically intended to degrade someone due to their race.

Te taitōkai aropā
Peer-on-peer sexual abuse

462. Within social welfare institutions, survivors described an embedded hierarchal environment where older or larger children would take advantage of those who were weaker or younger.[616] New residents might be targeted for sexual abuse during initiations including younger and smaller boys being forced to perform oral sex, and forced anal penetration of some boys with a broomstick handle.[617]

463. Sexual abuse was used as a form of retribution in some social welfare institutions by peers for ‘narking’. One Māori, European, French, survivor Mr SK (Ngāti Maniapoto, Ngāti Porou) shared how he was abused by his peers “I was stomped by five other boys. My pants were taken off and something or someone entered me.”[618]

464. Takatāpui and Rainbow children and young people were targeted due to their sexuality, gender expression or sex characteristics. Boys perceived as effeminate or homosexual were also at risk of abuse.[619] Survivor Sharyn, who is intersex and was repeatedly placed in boys’ homes, described being sexually assaulted by peers several times before staff recognised what was happening.[620]

“They would rape me. I think part of it was to explore me because I looked different. I had something between my legs but it wasn’t like theirs ... [Staff] eventually put me in my own room … they could see I was a victim.”[621]

465. The Inquiry heard evidence of sexual abuse occurring in Girls’ Homes and Boys’ Homes.[622] One survivor described how she was raped by older girls at a Girls’ Home.[623]

466. The move to mixed gender social welfare residences such as the Northern Residential Centre at Weymouth in the 1990s meant that girls became at risk of sexual harassment and abuse by male peers. This included name calling, verbal abuse, requesting sexual favours, exposing genitals to female residents[624] and unwanted touching.[625] Several female survivors were raped or otherwise sexually assaulted by males while in mixed gender care.[626]

Te tāruatanga o te whakataratahitanga
Routine use of solitary confinement

467. Most survivors who went through social welfare institutions spent time in solitary confinement or ‘secure’, either as a condition of entry, or as a form of punishment.[627] Children as young as 8 years old were placed in secure cells for days, weeks or months.[628] Conditions in secure cells were like those in prison.[629] In some settings such as Kohitere Boys’ Training Centre, secure units were based on the secure building at Arohata Prison.[630]

468. Evidence from survivors highlighted how solitary confinement was like a “jail cell”,[631] “an old dungeon”,[632] a “pig cell”[633] and “a maximum-security prison”.[634]

469. Secure units were considered necessary to contain and control residents and make life easier for staff. Placement in solitary confinement on admission was common practice in social welfare institutions until 1986, as was the placement for residents on remand awaiting trial or convicted of offending. Chappie Te Kani, Chief Executive of Oranga Tamariki acknowledged the conditions of secure units were ‘inhumane’ at the Inquiry’s State Institutional Response Hearing.[635]

470. Survivor Neta Kerepeti described how solitary confinement at Bollard Girls’ Home in 1975 was like jail:

“The secure units were covered with spiders. To make matters worse the doors were locked … there was a bed and a little toilet. No one bothered to come and check on me other than to put food through the sliding door.”[636]

471. Some secure units did not have beds, or only a metal or wooden frame. Survivors slept on mattresses that they rolled up and put away each day. Prof. Elizabeth Stanley told the Inquiry that the practice of taking mattresses away during the day was to “ensure discomfort”.[637] At Waikeria Borstal, Māori survivor John Issac recalled his clothes being taken away: “I was naked the whole time that I was in the secure unit.”[638]

472. Survivors described daily life in solitary confinement as demoralising. They were left alone, with little to do and no social contact or communication. Some were not allowed to exercise or out of their cells for days. Māori survivor Mr TG (Ngāti Rongomaiwahine) went into care when he was 12 years old. He told the Inquiry that being in solitary confinement at a boys’ home meant you were more locked up than if you were in jail.[639] Survivor David Williams (aka John Williams) described how being in secure made him think he was going mad:

“At times I wanted to die because your mind, you don’t talk to no-one, you’re by yourself, you sit on your bed. You know what that does to a child?”[640]

473. Expert witness Dr Enys Delmage explained to the Inquiry how being managed separately from peers, such as in secure areas like solitary confinement, can have a number of negative consequences:

“Peer socialisation is very important for the developing tamariki/child so protracted periods of separation are likely to break that social connection. Animal studies also indicate that the richness of the environment can influence healthy brain development and this would also be a consideration for young people being managed in restricted secure areas for protracted periods.”[641]

474. Expert witness Dr Sharon Shalev’s 2022 report, ‘Uses and abuses of solitary confinement of children in State-run institutions in Aotearoa New Zealand’, further described some of the effects being in secure could have on children and young people:

“Solitary confinement ‘attacks’ the isolated individual in two ways: it places them in highly stressful conditions, and it takes away the usual coping mechanisms – access to human company, nature, and things to do. Perhaps unsurprisingly, the documented adverse health effects of solitary confinement, both psychological and physiological, are wide ranging and long lasting.”

“Commonly reported problems include anxiety, panic attacks, depression, hopelessness, anger, poor impulse control, cognitive disturbances, perceptual distortions, paranoia, psychosis, and a significantly increased risk of self-harm and suicide. Physiological problems include gastro-intestinal and genito-urinary problems, insomnia, deterioration of eyesight, weakness, profound fatigue, migraine headaches, joint pains, and an aggravation of pre-existing medical issues.”[642]

475. Dr Shalev’s report highlighted that solitary confinement could be particularly damaging for those with pre-existing health conditions and who were at risk because of age, gender, disability or personal history.[643]

476. Staff manuals have required children in solitary confinement be: “constructively occupied as far as possible”,[644] with at least an hour of physical activity per day, since 1957.[645] However, many survivors told the Inquiry they had no reading material, no schooling and no access to other resources while in secure units.[646] Survivor Mr FI was 11 years old when placed in care at Epuni Boys’ Home during the 1970s. He told the Inquiry that he didn’t get to go outside for three weeks: “I had comic books ... but I would usually sit there and twiddle my thumbs and cry a lot.”[647]

477. Survivors in solitary confinement experienced demeaning treatment from staff. Māori, European, French survivor Mr SK (Ngāti Maniapoto, Ngāti Porou) recalled that when he asked about his parents, staff would look at him through peepholes in the door to his unit and tell him they were ‘dead’.[648] Survivors also experienced chores and punishments specific to secure units. Survivor Lindsay Eddy told the Inquiry that at both Stanmore Road Boys’ Home and Hokio Beach School, boys were made to stand all day in their secure cells.[649]

478. Secure units were a closed environment, out of sight of the rest of the institution. Children and young people in solitary confinement depended on staff to have their basic needs met. Some staff however, exploited the vulnerability of children who were locked in solitary confinement to enable their abuse.[650] For some survivors, the abuse they faced in secure units could be more severe and regular than in other institutional environments.

479. Survivor Daniel Rei Mr GO recalled a boy being beaten ‘severely’ in the secure unit at Kohitere Boys’ Training Centre. He stated: “There were many, many others, because boys got beaten for running away.”[651] Another survivor, Wiremu Waikari, also described regular assaults by staff in the secure unit at Epuni Boys’ Home and Kohitere Boys’ training Centre.[652]

480. The Inquiry heard multiple accounts of sexual abuse during solitary confinement at social welfare institutions.[653] Survivors described how some staff frequently used the isolated and locked nature of secure units to ‘create opportunities’ to sexually abuse children and young people in secret.[654] In many cases the identity of the abuser was unknown, and their abuse went undetected by others.

481. Survivor Andrew Meadows described sexual abuse by different staff at the Ōwairaka Boys’ Home secure unit in 1980: “It started when I was in the secure unit. On about three separate occasions, male staff came into my cell, while I was alone, and took advantage of me.”[655]

482. At Miramar Girls’ Home, the Inquiry heard that one staff abuser targeted girls when they were in solitary confinement and other staff were not present.[656] Irish and Māori survivor Ms GB (Ngāpuhi) told the Inquiry the abuse was pre-planned: “He always had a condom, so he knew what he was doing.”[657] Residents had previously warned the survivor about this staff member, and she was aware that other girls were sexually abused by him.[658]

483. Former social worker Edward Anand was convicted in 2016 on multiple charges of rape and indecent assault for sexual offending he committed between 1980 and 1986 at Elliot Street Girls’ Home in Ōtepoti Dunedin.[659] Māori survivor Ms HA (Tūhoe) shared how he sexually abused her and other girls at Elliot Street Girls’ Home’s secure unit:

“He raped me about six or so times down there. No one could hear me screaming. That didn’t just happen to me, he was also molesting my two sisters and other girls as well. He came down to secure and visited different cells ... [He] mostly abused us during the day.”[660]

Ngā rongoā hei aupēhi, hei mauhere kainoho anō hoki
Medication to control and restrain residents

484. This Inquiry has repeatedly heard how staff in social welfare institutions used medication including sedatives, anti-psychotics and anti-convulsants to control children and young people.[661]

485. Former staff member Patricia Lee worked as a matron’s assistant at Holdsworth from 1971 to 1973. She recalled ‘a dozen’ boys aged from 9 to 12 years old on medication including Largactil: “Medication tended to keep the boys a bit calmer, though I would imagine it would have also made them pretty scratchy or spaced out.”[662] Tiredness, weight gain, and ‘movement disorders’ are side effects of Largactil.[663]

486. Survivor Susan Kenny described being ‘drugged up’ following her admission to Kingslea in the late 1960s, when she was medicated with paraldehyde, Tryptanol and Largactil. She believes staff tried to use these drugs to prevent her running away: “I was unable to move, even if I wanted to. I was so heavily drugged … The medication made me heavily sedated and very fat.”[664]

487. Gary Hermansson, a staff member at Kohitere Boys’ Training Centre and Epuni Boys’ Home during the 1960s and 1970s, believed the administration of medication generally followed psychiatric assessment or professional diagnosis.[665] However, Mr Hermansson stated that “with the benefit of hindsight”, residents could have been put on medication, like Ritalin, “when they may have not needed to be”.[666] He explained how assessments from psychiatric or other medical professionals were rarely questioned by staff:

“There was the fairly typical stance adopted those days whereby those with specialist training, such as psychologists, and especially those with medical and psychiatric credentials, would be treated with great respect and deference, and challenging their opinions and recommendations would have been unlikely.”[667]

488. A survivor who went through Epuni Boys’ Home spoke about how children and young people would “all be on medication” at Epuni during the 1970s.[668] He explained medication would especially be handed out at night, so the children and young people would not “be any trouble”. He continued: “This medication sort of sedated us. The staff liked a nice quiet evening, not us all running around causing trouble.”[669] Survivor Sharon Byles recalled waking up ‘groggy’ from afternoon naps at Bollard Girls’ Home, and is now unsure whether she and other children were drugged:

“I wasn’t on any medication, so it seems funny I would wake up feeling groggy all the time. We had to have Milo before we went to sleep, they could have easily put medication in the drinks.”[670]

489. Department of Social Welfare psychologist Dr A Frazer collected statistical data on Miramar Girls’ Home residents from 1971 to 1974.[671] He found that because of assessments for “so-called psychiatric disorders”, 39 (22 percent) of the 180 girls studied were put on psychiatric drugs.[672] Similarly, at Epuni Boys’ Home, Dr Frazer assessed 250 adolescent boys from 1971 to 1973.[673] Of these boys, 75 (30 percent) were put on psychiatric drugs, while 13 were medicated for enuresis (bedwetting).[674]

Te āhua o te horopaki: Te whāngai rongoā i Fareham House
Setting Profile: Medicalisation at Fareham House

490. Opened in 1944, Fareham House was originally a child welfare home that predominantly targeted Māori girls.[675] In the early 1960s, Fareham House opened its doors to “troubled girls from all backgrounds”,[676] although Māori girls continued to make up more than 70 percent of the residents in the 1960s and 1970s.[677]

491. During the mid-1960s and early 1970s, social welfare psychiatrists at Fareham House undertook a “mass diagnosis” of girls with epilepsy, resulting in their “mass treatment”, by prescribing anti-convulsant medication without consent.[678] Mr Bell, the principal at the time, described this as “an effort to aid difficult disturbed children adjust and to give them an opportunity to establish acceptable patterns of behaviour”.”[679] Mr Bell stated in 1965 that he wanted to reduce running away through “some way of giving immediate sedation to the girls when they became disturbed”.[680]

492. From about 1967, every girl admitted to the home was referred to Porirua Hospital to undergo a brain scan called an electroencephalogram, leading to many being diagnosed with temporal lobe epilepsy and prescribed the anti-convulsant drug Nydrane.[681] Nydrane is an anti-convulsant, anti-epileptic medication, thought to be of low toxicity and therefore favoured as an anti-epileptic drug at the time.[682] This practice was described by a superintendent in 1969 as “drug therapy prescribed for inmates of Fareham house”, which followed “experimental drug treatment for disturbed inmates” at Kingslea Girls’ Home in Christchurch.[683] Mr Bell later stated in an affidavit to the High Court that “a number of girls were prescribed Nydrane” during his tenure[684]

493. Child epilepsy experts told the Inquiry that mass testing for epilepsy at the time was a reasonable request for patients entering a psychiatric institution.[685] However, because Fareham House was not a psychiatric institution, “the standardised approach of sending children for EEG [a brain scan known as an electroencephalogram] testing upon arrival at Fareham was not appropriate.”[686] The experts stated that an electroencephalogram test alone was “not a sufficient basis to make a diagnosis of TLE” (temporal lobe epilepsy).[687]

494. At times, girls from Fareham House were convinced to attend their electroencephalogram testing voluntarily at Porirua Hospital by being given privileges such as ice creams, with some seeing the experience as a “pleasant day out”.[688] ‘Results’ of the trial were recorded in a report titled Temporal Lobe Epilepsy – Related to Difficult Behaviour, prepared by Mr Bell, who had no medical qualifications. The report talks about a “recorded progress in social adjustment”, possibly linked to the use of Nydrane.[689]

495. Survivor Ms HV told the Inquiry that during her time at Fareham House in the late 1960s, she had an electroencephalogram that showed an abnormal graph, but that this was common at the time.[690] The test indicated that she had epilepsy.[691] She was prescribed Nydrane at least once a day and it made her feel “lethargic and sedated”.[692] She learnt later that she never had epilepsy and should never have been prescribed this medication.[693]

496. Some staff at Fareham House were critical of the use of medication. Concerns voiced by teachers, and overruled by Mr Bell, finally ended in 1971 when Mr Kildey arrived. He was employed as the new principal of Fareham House and was told by the children on medication that getting a ‘head test’ gave them anxiety, and they asked him if they were ‘mad’.[694]

497. Mr Kildey was concerned about whether medication would continue once the girls had left and said, “the drugs were doing what staff should be attempting to do”.[695] A 1969 report to the principal stated:

“I consider it thoroughly inadequate to continue attempting to deal with these children through comparatively untrained and inexperienced staff together with the present almost ‘blanket’ drug ‘therapy’ programme with minimal expert professional oversight.”[696]

498. Mr Kildey ended the mass medication practice and recorded in the 1971 annual report that it was the appropriate action to take, there were no negative impacts on the children’s behaviour, and that ‘normality’ returned to the residence.[697]

499. Evidence shows that from the late 1960s, 20 to 30 percent of girls at Fareham House were admitted, or ‘graduated’, to mental health settings after leaving.[698]

Te tūkinotanga i ngā whakanohonga ki ngā kaitaurima ā-kirimana
Abuse in placements with contracted care providers

500. Indirect care is when the State passes on its authority or care functions to another individual, entity, or service provider, and includes contracted care providers.[699] During the Inquiry period this was done informally and formally, with or without formal contracts. After 1989, children and young people in care experienced social welfare institutions’ placements with contracted care providers (also known as third-party providers, or section 396 providers).[700] While there are many types of third-party providers within the State care system most survivor evidence the Inquiry heard was about abuse that occurred in ‘boot camp’ settings such as Moerangi Treks in Ruatoki, Eastland Youth Rescue Trust near Opotiki and Te Whakapakari Youth Programme on Aotea Great Barrier Island.[701] Children were regularly sent to these programmes as an alternative to going to a youth justice facility.

501. Third-party providers set up programmes that they designed to provide for the rehabilitation of youths. The programmes offered activities such as wilderness training, designed to develop competence in the child or young person’s ability to cope, learn and experience a positive lifestyle with outdoor pursuits and life skills. However, children and young people placed in these programmes suffered neglect and often extreme physical, sexual and psychological abuse. The Inquiry heard many examples of violence from survivors who experienced abuse from third-party providers, some involving guns or death threats. Pākehā survivor Mr PM entered care at 12 years old. He described how at Te Whakapakari Youth Programme one staff member used extreme scare tactics:

“He made us dig our own graves. The holes were deep, and we were made to get in and lay face down. We weren’t allowed to look, and he threatened to shoot us. The supervisor started shooting into the air and we were screaming, begging for our lives and freaking out. It was horrifying. When we tried to get out of the holes, he would just kick us and beat us back in.”[702]

502. Third-party providers could provide care to both children and young people in need of care and protection, or as a result of an order by the Youth Court as an outcome of proven youth justice charges. At Te Whakapakari Youth Programme, for example, this meant that there was a mix of children and young people who required different types of care, and the programme was not adapted to meet the different needs of the two cohorts.[703] The Inquiry also received evidence of this occurring at Eastland Youth Rescue Trust.[704] This practice of mixing young people with those placed for a youth justice outcome was inconsistent with the general State care practices at the time and contrary to statutory criteria.[705]

503. Moerangi Treks was established in 1993, to provide a specialist youth residential rehabilitation programme in a wilderness setting. Instead, the Inquiry heard many survivor accounts of abuse. Māori survivor Mr TN (Ngāti Hako) entered care when he was 13 years old. He told the Inquiry how a Moerangi Treks staff member held a rifle to his head and told him to “shut the fuck up”.[706] Māori survivor Ronald Topia stated: “We had to do a lot of bushcraft and things of that nature, if we weren’t doing it up to standard, we’d get a smack and get verbally abused.”[707]

504. Survivor Mr UE described the physical abuse he suffered on his first day:

“The main tutor said, ‘Kia ora’. I replied, ‘Kia ora’, putting my stuff down on the table. Then at this moment he stood up and started to punch me in the head constantly until I was concussed, losing my balance.” [708]

505. Māori survivor Mr VP shared how Moerangi Treks staff psychologically abused him and caused him to be trampled by a horse.[709] Māori survivor Mr HC (Ngāti Porou, Te Arawa) told the Inquiry about boys carrying out pest control work during 1997, where they worked with cyanide despite being under 18, and were not paid for their labour.[710]

506. A Department of Social Welfare report into complaints of mistreatment at Moerangi Treks noted that survivors’ allegations of being hit in the head, choked with a rope and hit in the face with a gun “have been corroborated by more than one of the clients on the programme”.[711] The report’s conclusions included: “There is a substantial amount of evidence to suggest that physical abuse is a regular occurrence at Moerangi Treks. The abuse is systematic and harsh, and serious injuries have occurred as a result.”[712]

507. Survivors’ testimony suggests that violence and abuse was a ‘way of life’ at Moerangi Treks,[713] despite its Code of Practice stating that: “No form of physical or emotional punishment is acceptable for disciplining youths.”[714]

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Footnotes