11. During the Inquiry period, many whānau, kainga (families) and communities needed support to care for their children, young people and adults at home or within their community. Without this support, many children, young people and adults were placed in State and/or faith-based care. People placed in care needed support, strong protection and to be safeguarded against abuse and neglect. Instead, many were placed in care facilities with institutional environments and practices that heightened the risk of abuse and neglect.

12. Abusers misused their positions of power and control over people in care to inflict at times extreme and violent abuse, or to neglect people in their care. Abusers sometimes took calculated steps to conceal their actions which allowed them to continue, at times, acting with impunity.

13. Many staff and carers who witnessed abuse and neglect, or were told about it, did nothing. Some bystanders did complain or raise concerns, but often with limited success.

Ngā tamariki, rangatahi, pakeke kei ngā pūnaha taurima
Children, young people and adults in care

Ngā tamariki, rangatahi, pakeke kei ngā pūnaha taurima e tika kē ana kia tautokona kia tauāraitia
Children, young people and adults in care needed support, protective factors and safeguarding

14. Children, young people and adults in State and faith-based care were diverse, with diverse care and support needs. Although each person in care was unique, every person needed support and caring, strong protective factors and safeguarding.

15. Safeguarding is a preventative approach to reduce the risks of abuse and neglect for people. In care settings, safeguarding includes standards of care, appropriate recruitment, adequate staff resourcing, diversity, training and development, and child protection policies and processes. This includes complaints policies that promote and prioritise the safety of those in care, while maintaining their rights and freedoms.[1]

16. Strong ‘protective factors’ refers to a set of internationally recognised factors that contribute to resilience because they promote healthy development and wellbeing and can reduce the risk of experiencing abuse and neglect.[2] These factors are a combination of personal, parental and environmental factors. People have strong protective factors if they:[3]

a. maintain strong connections with family, kainga, whānau, hapū, iwi and community
b. have good self-esteem or personal confidence and understand who they are and their place in the world
c. for Māori, have full authority over their kāinga (home, residence, village,) to live as Māori, and connection to their whakapapa, whānau, hapū and iwi
d. have family cohesion and parental resilience
e. have supportive and trustworthy peers and adults in their lives (in addition to their direct carers)
f. understand their rights and how they should be treated
g. understand appropriate and inappropriate behaviour, personal safety and what they can do in difficult situations.

17. Strong protective factors in whānau, children, young people and adults significantly reduces the likelihood of entry into care. In care settings, protective factors can reduce the risk of abuse and neglect and increase a person’s resilience to navigate difficult situations.[4]

He mōtika i ōatitia i te Tiriti o Waitangi hei tauārai mō ngā tamariki, rangatahi me ngā pakeke Māori
Rights guaranteed in te Tiriti o Waitangi protect tamariki, rangatahi and pakeke Māori

18. The Inquiry’s Terms of Reference required it to be underpinned by te Tiriti o Waitangi and its principles.[5] Part 1 of this report explains that the Inquiry has sought to centre te Tiriti o Waitangi in all its work. It considered the abuse and neglect of tamariki, rangatahi and pakeke Māori in the care of State and faith-based institutions during the Inquiry period through a Tiriti o Waitangi lens. This included using te Tiriti o Waitangi as a standard against which actions or omissions by the Crown and faith-based care institutions must be assessed.

19. In Part 1 of this report, the Inquiry described te Tiriti o Waitangi, its principles and how these are relevant to tamariki, rangatahi and pakeke Māori in care and their whanau, hapu and iwi. Through te Tiriti o Waitangi, the Crown made a series of guarantees to Māori including that it would protect the right to exercise tino rangatiratanga.[6] This right included the full authority of Māori over their kāinga, the right to continue to organise and live as Māori, and the right to care for and raise the next generations.[7]

20. The rights guaranteed in te Tiriti o Waitangi reinforce many protective factors. For example, connection to whakapapa, whānau, hapū and iwi are taonga protected by te Tiriti o Waitangi.

21. Dr Moana Jackson (Ngāti Kahungunu, Rongomaiwahine, Ngāti Porou) told the Inquiry that;

“Taking away a people’s political and constitutional power to determine their own destiny breaks the fundamental construct that ensures their independence and thus the authority to make the best decisions for themselves.”

22. Had these rights been upheld during the Inquiry period – such as the right to tino rangatiratanga over kāinga, and the right to continue to live in accordance with indigenous traditions and worldview guaranteed by te Tiriti o Waitangi principle of options – these would have been amplified protective factors for tamariki, rangatahi and pakeke Māori, reducing entry into care and the risk of abuse and neglect while in care.

23. Parts 3- 6 of this report describe how many whānau, hapū, and iwi were not empowered to care for and raise their tamariki, rangatahi or pakeke Māori as guaranteed to them in te Tiriti o Waitangi.[8] When tamariki, rangatahi and pakeke Māori were removed from their whānau, hapū and iwi and placed into care, it removed the ability and power of whānau, hapū and iwi to care for and nurture the next generation, to regulate the lives of their people and to transfer mātauranga Māori.

24. The ongoing, intergenerational effects of colonisation and continuing assimilation polices and urbanisation during the Inquiry period meant that many tamariki, rangatahi and pakeke Māori did not have an understanding of who they were and their place in the world. Some had connections with their whakapapa, whānau, hapū and iwi severed. Many held shame or mamae, rather than pride in their culture.

25. The Crown’s failure to uphold these rights during the Inquiry period was a breach of the principles of tino rangatiratanga, kāwanatanga, partnership, active protection and options.

He mōtika tangata e tauārai ana i ngā tamariki, rangatahi, pakeke kei ngā pūnaha taurima
Human rights protect children, young people, adults in care

26. Part 1 of this report sets out the core themes relevant to human rights that the Inquiry used to guide its work, including identifying where the State and faith-based institutions failed to uphold the human rights of children, young people and adults in their care.

27. Human rights recognise that some disadvantaged, minority or Indigenous groups, including whānau and individual mothers or fathers, may need special measures to achieve equity, or eliminate inequity, alongside similar groups.[9] Special measures include targeted financial support or priority access to healthcare, educational, employment or housing services. Special measures also include protections for Indigenous rights. Whānau and mothers or fathers who face the biggest barriers, or who are the most marginalised or vulnerable, should have priority access to these measures.[10]

28. During the Inquiry period, many whānau, caregivers or individual mothers or fathers were not always supported by the State to care for their children, young people or adults at home. Many struggled with financial hardship, unemployment, housing instability and parental mental distress. Many did not have access to the concrete support or special measures they needed to help build and maintain whānau and / or community cohesion and resilience, and care for their loved ones themselves.

29. Human rights recognise that children, young people, Deaf people, disabled people and people experiencing mental distress are distinct groups that also require special measures (or supports), particularly protective measures.[11] In care settings, this means special protective measures like comprehensive standards of care, as well as special assistance measures for example, non-speaking disabled people in care having access to communication and accommodation supports to assist decision-making.[12]

30. During the Inquiry period, the lack of special protections or measures for people in care were factors that contributed to abuse and neglect. For many Deaf people and disabled people in care, the absence of human rights protections and special measures not only increased their risk of experiencing abuse and neglect, but also prevented them from being able to communicate what was happening to them.

Ko ngā take whakauru ki ngā pūnaha taurima i tahuri kē hei take mo te mahi tūkino
Factors for entry into care became factors for abuse and neglect in care

31. Many of the circumstances that made it more likely a child, young person or adult would enter care often became the factors for why they were more susceptible to, or at an increased risk of, abuse and neglect in care.

32. These factors included:

a. being raised in poverty and experiencing deprivation
b. being disabled with unmet needs
c. being Māori and racially targeted
d. being Pacific and racially targeted
e. being Deaf with unmet needs
f. experiencing mental distress with unmet needs
g. being Takatāpui, Rainbow, MVPFAFF+, gender diverse or transgender and being targeted.

33. If a person had experienced significant or multiple adverse childhood events prior to entering care, these became the factors for why they were more susceptible to, or at an increased risk of, abuse and neglect in care. Significant adverse childhood events may include:

a. experiencing violence, abuse, or neglect in private homes or in other care settings
b. witnessing violence in private homes, in the community or in other care settings
c. having a family member or a peer in a care setting pass away, or attempt or die by suicide
d. aspects of a person’s environment that undermined their sense of safety, stability and bonding, such as growing up in a private home or in other care settings:

i. with parents, caregivers, or peers experiencing substance use problems
ii. with parents, caregivers or peers experiencing mental distress
iii. where there is instability due to parental separation or household members being incarcerated[13]
iv. living in an under-resourced private home or becoming homeless
v. experiencing unsupported and weakened family and cultural structures
vi. being in families and communities that were unsupported because their needs had not been adequately assessed or met 

e. having a deferential attitude to people in positions of authority, including faith leaders and medical professionals
f. other reasons such as age or gender.

34. Experiencing or being any combination of the factors set out above could also make a person susceptible to abuse and neglect in care.

35. These factors were underpinned by societal attitudes, like discrimination based on racism, ableism, disablism, sexism, homophobia, transphobia and negative stereotypes about children and young people, poverty and welfare dependency.

36. Most survivors had or experienced many of these factors, which heightened the risk of abuse and neglect when they were in care. For example, whānau hauā, tāngata whaikaha and tāngata whaiora Māori experienced high rates of abuse and neglect in care and multiple types of abuse, particularly racial and cultural abuse and neglect.

37. The longer someone was in care, the more likely they were to experience abuse and neglect. Many disabled people were placed in institutional care permanently and from a very young age.[14]

Ngā kaitūkino
Abusers

38. Abusers were male, female, young, old, Pākehā, Māori, Pacific Peoples, people from other ethnic groups, leaders, respected members of communities, unskilled workers, caregivers, volunteers, and educated professionals including teachers, social workers, psychologists, psychiatrists and medical staff. They were also religious leaders including bishops, priests, religious sisters, religious brothers, deacons, lay people. Abusers were single, married with children, heterosexual, homosexual and celibate people.

39. There was no single, easily identifiable ‘bad apple’ abuser,[15] although many held highly skilled or senior positions and some were charismatic leaders.

I kōtiti kē te whakamahi a ngā kaitūkino i tō rātou mana whakahaere hei taki mahi tūkino
Abusers misused their positions of power, control to carry out abuse and neglect

40. Most abusers were adults, which gave them inherent power over the children, young people and adults in their care. Many survivors felt afraid to disclose abuse because of the power adults had over them. Māori survivor Mr SN, who was placed into foster care when he was 6 years old, told the Inquiry:

“I was too scared to tell a staff member what Mr Ansell was doing ... I found it hard to relate to adults, especially when they usually did not believe what I was saying anyway. The staff members who were abusive knew this and so could cover up what they were doing because they knew nobody would believe me or other boys like me.”[16]

41. Abusers were able to misuse the power, control and opportunity that came with their positions to perpetrate abuse and neglect, sometimes going undetected for extended periods of time. The extent of their power, control and the opportunities to abuse, differed from position-to-position. Positions that allowed a high degree of unsupervised contact with, or control over, people in care provided the greatest opportunities for abuse for example, positions in foster homes, boarding schools, institutions and residences.

42. Staff and caregivers in institutional facilities and residential settings had almost total power and control over the lives of people in their care.[17] Fran Erikson, a manager at Kingslea Girls’ Home in in Ōtautahi Christchurch in 1995, said at the time:

“What has been reported may only be the tip of the iceberg in that the residential clients are predominately powerless against persons in authority, to all intents and purposes.”[18]

43. Foster parents similarly had almost total power and control over a foster child or young person’s life. Abusers who were foster parents were in private family group homes, away from other adults who might intervene, which increased their opportunities to abuse and meant they could operate with enhanced impunity.

44. Staff and volunteers in school hostels or boarding facilities held positions that gave them considerable power and control over the daily routines of those in their care. Abusers were able to use these positions of power and control to carry out abuse and neglect, with high rates of sexual abuse in some settings.

45. Medical professionals and healthcare workers held positions that gave them coercive statutory powers to place people in care (at times without consent), decide their treatment including, at times, using compulsory orders and decide what supports they could access.[19] Some people misused the power and control that came with these positions to inflict certain types of abuse and neglect, such as the extreme medical abuse and neglect demonstrated in the Inquiry’s report Beautiful Children: Inquiry into the Lake Alice Child and Adolescent Unit.[20]

46. Police officers also held positions that gave them coercive statutory powers over a child, young person or adult, including the ability to take someone into custody, and question and charge them with an offence.

47. Child welfare officers, social workers and field officers held positions that gave them power and control to decide whether people in care were safe, to recommend they be moved and to where, and to take people off site.[21]

48. Within faiths, abusers occupied a wide range of positions. Many of them benefited from the elevated moral authority and / or power attributed to people in religious roles. Examples include the positions of a bishop, pastor, minister, brother, priest, elder or shepherd. It includes positions at faith youth camps, Bible study groups and Sunday schools, and one-on-one pastoral or spiritual direction. Many lay people who volunteered or worked for faith-based entities also enjoyed an assumption of moral authority. Abusers in these positions used their elevated power to carry out abuse and neglect, often within a religious framework or using religious beliefs to justify abuse.

49. Many of those accused of abuse within the Catholic Church were in positions of leadership and authority. Data from the Catholic Church showed that among the diocesan clergy,[22] there were 378 reports of abuse made against 182 individuals, constituting 14 percent of all diocesan clergy during the Inquiry period. Among male members of religious orders,[23] 599 reports of abuse were made against 187 individuals, representing 8 percent of all male members of religious orders during the same period. The remaining 78 percent of perpetrators included female members of religious orders, lay people (staff and volunteers), trainees, other residents, unnamed, unknown and unidentifiable.[24]

Tērā ngā kaitūkino i teka, i whakangū i ngā purapura ora, ka whakakōtiti i ētahi atu hei karo mō a rātou mahi
Abusers lied, silenced survivors and manipulated others to avoid accountability

50. Many abusers were adept at hiding their abuse or avoiding accountability once concerns had been raised. Some abusers can be adept at hiding their abuse or avoiding accountability for long periods because they: [25]

a. occupy respected positions of authority in care settings or are the primary caregiver
b. are highly skilled at manipulating and deceiving people around them, including deceiving care system checks
c. are highly skilled at neutralising, silencing and denying what has happended in an attempt to minimise their wrong-doing[26]
d. appear very successful at work and in their relationships
e. pathologically lie.

51. Abusers during the Inquiry period would often lie, and many abusers called survivors liars.[27] Abusers would often take steps so that survivors who had disclosed abuse or neglect were not believed.[28]

52. Ross Browne was the chaplain and teacher at Dilworth School (Anglican) in Tāmaki Makaurau Auckland from 1989 until 2006 when the Principal, Donald McLean, and the Board of the School agreed to a “dignified exit” after allegations he had repeatedly sexually abused multiple young boys.[29] In response to clear evidence of his abuse, Ross Browne categorically denied the offending. Ross Browne’s denial of the abuse was described in Hon Rodney Hansen CNZM QC’s report to the Anglican Diocese of Auckland:

“[Ross Browne] argued that there was no truth or logic to the assertion that he caused or encouraged boys to masturbate in class. He said such an allegation ‘defied common sense’. He maintained that actions he took to control a class containing some unruly individuals were misinterpreted and misrepresented when recalled by class members over ten years later.”[30]

53. At Ross Browne’s sentencing in 2021, Justice Toogood described the repeated sexual abuse as predatory and pre-meditated and said:

“The scale and duration of your offending … indicates that the scale of the actual offending goes much wider than the complainants whose experiences have led to these charges.”[31]

54. Abusers were often adept at manipulating and deceiving those around them to conceal their abuse and neglect. They would rely on their authority and status, like their skilled position, professional qualifications or being a member of a faith, to convince others they were trustworthy.[32]

55. Many abusers developed strong relationships with their colleagues, which worked in their favour when concerns were raised. Rod Morine was a residential social worker at Kingslea Girls’ Home in Ōtautahi Christchurch in the 1990s and was “seen to work hard for staff … and had a reputation for getting people out of trouble.”[33] When concerns were raised about him, his colleagues saw these as a management plot against him:

“… in hindsight we … were quite intimidated by Rod due to the power he had across campus with staff and within the [Public Service Association]. This may be (my opinion only) why some of the hearsay concerns were never fully followed up on.”[34]

56. Abusers would use their positions to silence or prevent survivors from disclosing abuse or neglect.[35] They would tell survivors that if they disclosed abuse, they would not be believed.[36] Others bullied survivors, threatened further abuse[37] and, in some instances, threatened to kill them[38] or hurt members of their family[39] if they told anyone. Some used their positions to provide incentives to survivors to prevent them from telling someone, such as improved living conditions or rewards.[40]

57. Some abusers found, or put, themselves in positions that enabled them to manipulate complaints processes in their favour. At Gloriavale Christian Community, for example, founder Neville Cooper (Hopeful Christian) dealt with all reports of sexual or physical abuse from its founding in the 1970s until the early 1990s, and was subsequently convicted of sexual offences against a community member.[41]

Tērā ētahi i tūkino anō i a rātou i roto i ngā pūnaha taurima
There was peer-on-peer abuse in care

58. Some survivors were abused by others of a similar age, or those placed in the same care setting, in what is known as ‘peer-on-peer’ abuse. In care settings, a culture of physical or sexual violence could be established through staff condoning or even encouraging peer-on-peer abuse between residents.[42] Deaf NZ European survivor Mr JS described his experience of sexual abuse after arriving at Van Asch College in Ōtautahi Christchurch in 1979:

“The older boys would often act as a pack and they would target me ... About three times, boarding staff saw this same group of boys target me, take my pants off and try to assault me. Every time, the staff just laughed and did nothing. They found it funny.”[43]

59. The risk of peer-on-peer abuse in a care setting increased when the abuser knew the staff member or carer would not hold them to account. Māori survivor Gina Sammons (Ngāti Kura), who was first placed in foster care with her two sisters when she was 2 years old, told the Inquiry:

“Tanya was also sexually abused by our oldest foster brother when she was around 6. She confided in the second brother about what had happened, but he told our foster mother, who then told Tanya she was lying and beat Tanya for talking about it. After that, the second brother also began sexually abusing Tanya, and later the adopted brother who raped me also abused her. Tanya didn’t tell anyone else after that first time. She had learnt what the consequence was for talking about it.”[44]

He maha ngā kaitūkino kīhai i whakamaua mō a rātou mahi, kātahi ka tohe herekore tonu
Many abusers were rarely held to account and acted with impunity

60. Abusers were rarely held to account for their abuse and neglect. Even when concerns were raised or complaints were made, many abusers manipulated those around them to undermine the person making the complaint and the complaint process.[45] Institutional and system failures made it easier for many abusers to conceal their actions, interfere with complaints processes and continue abusing often with a sense of impunity.

Tērā ētahi i whai pānga mai e tika kē ana kia noho tauārai mō te hunga i ngā pūnaha taurima
Bystanders had a critical role in safeguarding people in care

61. Staff, volunteers and carers are a critical part of safeguarding people in care. They can be the first to see signs of abuse and neglect and are often the only adults present who can step in to prevent and respond to it. The Inquiry uses the term ‘bystander’ in this report to refer to staff, volunteers and carers who observed or witnessed abuse and neglect committed by an abuser of a child, young person or adult in care and had the opportunity to condone, intervene or do nothing. The Inquiry does not consider it appropriate to include children, young people or adults in care in the definition of bystander.

62. Many bystanders during the Inquiry period did try to intervene or report abuse and neglect but were often undermined or bullied by those around them. Some even lost their positions as a result of raising their concerns.

63. The Inquiry heard from many survivors who disclosed abuse and neglect to staff, volunteers, carers and bystanders, but no steps were taken to report the abuse and neglect or stop it happening again.[46] Some staff, volunteers or carers would make excuses for the abuser or dismiss the disclosures as lies.[47] NZ European survivor Mr UD, who was first taken into social welfare care when he was 6 years old, told the Inquiry about his attempts to disclose being sexual abused at Hokio Beach School near Taitoko Levin:

“When you’re a little boy you put confidence in someone and they fail you, then you shut down and you lose hope.”[48]

64. Some survivors told the Inquiry that, even without making a disclosure, staff, volunteers or carers must have been aware of the abuse and neglect and, if they did not know, they should have known.[49] Without disclosure, staff and carers should have noticed or recognised the obvious physical signs or behavioural changes that indicated abuse or neglect in care, like fresh bruising, bleeding, fractures, survivors saying they had abdominal or rectal pains, bloody clothing or bedding, bed wetting, suddenly fearing other staff or carers, malnourishment from lack of food or poor personal hygiene from neglectful care.

65. Many staff, volunteers, carers and bystanders consistently failed to intervene to stop or report abuse and neglect because:

a. the people in their care had become dehumanised in their eyes, so they no longer cared what happened to them
b. they gave abusers the benefit of the doubt, due to personal relationships, grooming and unconscious bias
c. they were reluctant to intervene due to fear of reprisals, or there was an institutional culture that discouraged or suppressed intervention
d. they were not trained to identify signs of abuse and neglect
e. they had become desensitised to abuse and neglect because it was commonplace and normalised in the care setting

f. there was no legal mechanism that required reporting for much of the Inquiry period (voluntary reporting was introduced in 1989 and reporting protocols for agencies and care providers in 1995).[50]

66. Dr John Crawshaw, Ministry of Health’s Director of Mental Health and Director of Addiction Services, discussed the effects of institutionalisation on both staff and people within care settings:

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

The institutional environment was a factor as to whether some staff or carers would intervene when they saw signs of abuse or neglect.”[51]

67. The high rates of abuse and neglect during the Inquiry period could have been much lower if all staff, volunteers and carers had been trained to recognise signs of it and had strong and clear incentives or direction to report it, such as mandatory reporting obligations.

He akonga i kitea he mea i panonihia
Lessons identified and changes made

68. This section relates to clause 31(e) of the Terms of Reference, which requires the Inquiry to report on the lessons learned and changes made to prevent and respond to abuse and neglect.

69. The lessons identified are stated definitively for clarity, even though it is generally unclear to what extent the State did in fact ‘learn the lesson’. In most cases, the changes made reflected aspects of a lesson learned were hindered by implementation issues or were only applied to discrete parts of care settings, which limited their potential to safeguard people in care.

70. The lessons described below relate to:

a. lessons identified and changes made for families, whānau and people in care
b. lessons identified and changes made about abusers
c. lessons identified and changes made about reporting abuse.

71. The sections on lessons identified or changes made set out below and throughout this part of the report are not exhaustive.

He akonga i kitea he mea i panonihia mō ngā whānau iwi kē, Māori mai me te hunga i ngā pūnaha taurima
Lessons identified and changes made for families, whānau and people in care

72. The State learned that some families, whānau, mothers and fathers needed special measures to care for their loved ones at home. From the 1970s onwards, the State made changes to legislation to provide some support, including financial, to families in need.

73. The State learned that families, whānau and communities needed to have much greater, direct roles in care. From the 1980s onwards it made legislative changes to most settings to bring families and communities closer to care. For example, in 1989 there were large-scale changes to education and social welfare settings. The Education Act 1989 devolved the State’s responsibility for running State and State-integrated schools to Boards of Trustees elected by parents and communities.[52] The Children, Young Persons and Their Families Act 1989 introduced greater participation by whānau, hapū, iwi and extended family in decision-making about children and young people, including family group conferences.[53]

74. The State learned that it needed to value Māori identity, culture and connections. From the late 1980s onwards, legislation began to include limited references to the principles of te Tiriti o Waitangi[54] and tikanga Māori.[55] However, there was never any explicit legislative protection of or reference to the rights guaranteed in the text of te Tiriti o Waitangi, such as tino rangatiratanga.

75. The State learned that it needed to legislate to protect the rights of people in care. Between 1986 and the early 1990s, the State began to protect the basic legal rights of some people in care, including rights to access to information, rights to an advocate, visits from family and complaints processes. These protections were limited to children, young people and adults in care in State residences or subject to compulsory mental health treatment orders.[56] There was no explicit reference to the human rights of people in care or to the rights guaranteed in the text of te Tiriti o Waitangi in care-specific legislation.

76. There were initiatives in some settings, like education, from the 1980s to help children and young people understand and identify sexual abuse and ways to safely respond to and report abuse.

77. The State started to recognise the need for people in care and their whānau to have access to information about themselves from their time in care, which was reflected in the Official Information Act 1981 and the Adult Information Act 1985. 

78. To a lesser degree, faith-based institutions introduced components of safeguarding and protective factors from the late 1980s. These changes tended to be slow and dependent on individual local leaders for introduction and implementation.

He akonga i kitea he mea i panonihia e pā ana ki ngā kaitūkino
Lessons identified and changes made about abusers

79. The State learned that safety checks, which include vetting and reference checking, were a critical first step to prevent abusers from entering a care setting, although relevant legislative changes were not made during the Inquiry period.

80. The State also began to learn that other factors, like effective, accessible complaints processes, staff training and accountability were critical to preventing and responding to abuse and neglect. However, changes were piecemeal and did not apply consistently across all settings.

Ngā akoranga kua tautuhia me ngā panonitanga mō te whākina tūkino
Lessons identified and changes made about reporting abuse

81. The State began to learn that staff and carers needed training to know what the signs of abuse and neglect are, and clear policies and processes to follow on what to do when they recognise those signs.

82. From 1995, legislation required the Director-General of Social Welfare to promote awareness of abuse, how to prevent it, how to report it, and to develop, implement and monitor reporting protocols for all care workers.[57]

83. The State made changes to legislation in 1989 to encourage anyone to report abuse or neglect of a child or young person to a social worker or NZ Police and to protect anyone who made such a report.[58] This led to an increase over time in reports of alleged child abuse, neglect and insecurity of care, mainly in relation to private homes.[59] However, the legislation did not make it clear that staff and carers should, or must, report signs of abuse and neglect in care.

He kōrero mutunga mō te hunga i te pū o ngā mahi tūkino
Conclusion on the people at the centre of abuse and neglect

84. People in care needed support, strong protective factors and safeguarding. Te Tiriti o Waitangi and human rights were an additional layer of protection for children, young people and adults in care and their whānau, hapū and iwi. However, breaches of te Tiriti o Waitangi contributed to many tamariki, rangatahi and pakeke Māori entering care and increased their risk of being abused or neglected in care. Many whānau and people in care did not have the protections and reasonable accommodations they needed and were entitled to as part of their human rights. Many people in care did not have the support, protective factors or safeguarding they were entitled to.

85. People in care relied on the adults around them to care for them, to protect them from abuse and neglect and, if it happened, to intervene and stop it. Some of the adults that people in care relied on to safeguard them were abusers. Many abusers were predatory and misused their positions of power and control to carry out serious and, at times, extreme, extensive and depraved abuse and neglect. Some abusers were peers of those in care. Abusers were rarely held to account. Many abusers acted with impunity and entitlement because of the failures of multiple, interconnected institutional factors.

86. Staff and carers who worked or volunteered in care settings should have intervened to protect people in care when they saw abuse and neglect or signs of it. Many did not. For many staff, volunteers and carers that were bystanders and observed or witnessed a situation of abuse and neglect, there were negative consequences if they spoke up, such as being bullied by other staff members or losing their jobs. Bystanders often gave the abuser the benefit of the doubt and dismissed those survivors who were brave enough to tell them what was happening. Many staff, volunteers and carers lacked training or were desensitised to abuse and neglect because it had become so normalised. None had an obligation to mandatorily report signs of abuse and neglect in care.