87. Standards of care set the baseline for how the rights of people in care will be protected and how they will be kept safe from abuse and neglect.[62] They prevent and respond to abuse and neglect because they make it clear to everyone what their rights and obligations are and what is unacceptable.

a. People in care know how they will be kept safe, what their rights are and how these will be protected, and their whānau and community know too.
b. Institutions and foster carers know what care they need to deliver based on the standards.
c. Oversight and monitoring bodies know what institutions and foster carers should be doing and when they are failing.

88. Standards of care were routinely breached throughout the Inquiry period. In many institutions, residences, family homes and foster homes, schools, hostels, and transitional and law enforcement settings, breaches of standards of care were serious and unlawful. European survivor Lindsay Roxburgh, who attended Dilworth School in Tāmaki Makaurau Auckland in the 1990s, told the Inquiry:

“Victims of abuse were everywhere. It was an unspoken existence.”[63]

89. Breaches of standards of care varied in severity. Many were extremely serious such as unconsented medical treatment and sexual abuse, some appeared minor such as infrequent visits to State wards in care, but all contributed to abuse and neglect, or were themselves abusive and neglectful.

90. The first section of this chapter looks at what standards of care were in place across all care settings. It responds to clauses 31(b) and 10.2(c) of the Terms of Reference. It looks at whether standards were set out in legislation and if these applied consistently to all people in care and all care providers. It also looks at how accessible they were to all staff and carers, people in care, their family, whānau and community. The second section of this chapter looks at breaches of standards of care, in line with clause 33 of the Terms of Reference.

Ngā paerewa i roto i ngā pūnaha taurima i te wā o te Pakirehua
Standards of care during the Inquiry period

Ngā paerewa atawhai e tika kē ana hei aukati mahi tūkino
Common standard of care to prevent abuse and neglect

91. Before and throughout the Inquiry period, disability and mental health, social welfare and parts of education settings had common legal standards to prevent ill-treatment, later called abuse and neglect. These common standards were all similar to this standard for institutional care which had been in place since 1911.

“Every Superintendent, licensee, officer, nurse, attendant, householder, or other person having the oversight, care, or control of any mentally defective person, or employed in any institution, house, or place in which any such mentally defective person resides, who strikes, wounds, or ill-treats, or wilfully neglects, any such mentally defective person is guilty of an indictable offence.”[64]

92. Before and throughout the Inquiry period, across all State and faith-based care settings it was a criminal offence to sexually abuse or indecently assault a person in care (consent was not a defence),[65] with special provisions for women and girls, regardless of age, in institutional care.

“Every person is guilty of an indictable offence who has or attempts to have carnal knowledge of any female who is detained under the provisions of the Act, or is otherwise under oversight, care, or control as mentally defective [consent is no defence].”[66]

93. Neglect and ill-treatment / abuse were also unlawful in Deaf, disability and mental health settings, social welfare settings and parts of education settings. From 1961, neglect and ill-treatment / abuse were unlawful in all settings including all parts of education and faith-based care settings.

Kāhore he wāhi mo te Tiriti o Waitangi i roto i ngā paerewa atawhai
Te Tiriti o Waitangi was absent from standards of care

94. In Part 6 of this report the Inquiry noted that the Crown’s te Tiriti o Waitangi obligations include ensuring the Crown, and as appropriate other institutions, recognise Māori rights and values and give effect to the Crown’s te Tiriti o Waitangi obligations.

95. During the Inquiry period, there was no legislative direction that standards of care should give effect to the rights guaranteed to iwi and hapū in te Tiriti o Waitangi or incorporate te Tiriti o Waitangi itself. It was left to government agencies and individual institutions to decide if and how to incorporate te Tiriti o Waitangi into their standards of care. The Inquiry did not see any standards of care that explicitly incorporated te Tiriti o Waitangi or gave effect to the rights of iwi and hapū as expressed in te Tiriti o Waitangi, such as the right to exercise tino rangatiratanga or that explicitly provided for te Tiriti o Waitangi principles of partnership, active protection or equity.

96. Up until the late 1980s the Crown and government agencies developed standards of care without hapū or iwi input, undermining both tino rangatiratanga and te Tiriti o Waitangi principle of partnership. This represented a missed opportunity to incorporate tikanga Māori and Māori models of care into standards that reflected te ao Māori, matauranga Māori, tikanga and te reo Māori, and to ensure connections to culture and to whānau, hapū and iwi were maintained. The Inquiry did not see any evidence of standards of care that sought to achieve equitable outcomes for tamariki, rangatahi and pakeke Māori in care, even though over-representation of Māori in care settings was a known issue from the 1960s and Māori were the majority in social welfare care settings. This was a breach of both the active protection and options principles of te Tiriti o Waitangi, which arise from the guarantee to Māori of both tino rangatiratanga and the rights and privileges of British citizenship under article 3.[67]

97. The Inquiry did observe that from the mid-1980s onwards there were some attempts made to include aspects of te ao Māori, tikanga Māori and te reo Māori in some care settings.

Kāhore i tino kitea ngā mōtika tangata i roto i ngā paerewa atawhai
Human rights were largely absent from standards of care

98. For most of the Inquiry period, standards of care did not refer to or provide for the human rights of children, young people or adults in care.

99. From 1950 - 1996, in Deaf, disability and mental health settings there was no legislative direction that human rights should be explicitly protected and fulfilled in standards of care. It was left to government agencies and individual institutions to decide whether to incorporate human rights into their standards of care. Some did. From 1996, several human rights obligations were expressly included in the Code of Health and Disability Services Consumers’ Rights, such as the right to dignity. There were exclusions for some people in care for example, people under compulsory mental health treatment orders were excluded from the Code’s right to give informed consent to treatment.[68]

100. From 1950 - 1986, in social welfare settings, the Department of Social Welfare’s standards of care did not explicitly incorporate or reference the human rights of people in care. From 1986, regulations prohibited humiliating or degrading treatment of children and young people in social welfare residences, but there were no other explicit references to human rights in social welfare settings.[69]

101. During the Inquiry period, standards of care in education, faith-based and transitional and law enforcement settings did not explicitly refer to or incorporate human rights. The Ministry of Education did issue guidelines in 1997 to schools referring to the dignity of children and young people.

Ngā paerewa atawhai i ngā takinga whaikaha, hauora hinengaro
Standards of care in disability and mental health settings

102. Between 1950 to 1992, it was left to government agencies and institutions to decide whether and how they would protect the rights of the children, young people and adults in their care. Some institutions developed their own standards to protect the rights of people in their care with wide ranging approaches. For example, the 1988 Statement of Rights for Residents of Templeton Hospital, a psychopaedic institution in Ōtautahi Christchurch, was entirely patient and human rights focused:

“All residents ... should have and freely exercise the following rights:

1) The right to dignity and respect.
2) A right to adequate protection from any physical or mental abuse and exploitation.
3) The right to proper daily care. This includes proper exercise, nutrition, sleep, medical attention, dental care and hygiene.”[70]

103. From November 1992, the basic rights of people subject to compulsory mental health treatment orders were protected in legislation.[71] They had:

• the right to know their rights while in care and have a copy in writing:
• the right to an interpreter, including for te reo Māori or to meet their communication needs
• access to independent legal and psychiatric advice
• the right to company
• the right to send and receive mail and make phone calls.

104. A complaints process was also included which provided important protections including the requirement for directors of area mental health services to rectify matters and rights of appeal.[72] There was also a general emphasis on family connections and cultural identity and connections to support protective factors while in care.

105. From May 1993, for people in the care of other disability and mental health service providers, the Ministry of Health set standards of care through its health service contracts.[73] There was only a legislated requirement in the Health and Disability Services Act 1993 for standards of services (rather than care or preventing and responding to abuse or neglect in the care of a provider), and general objectives to secure the best health, care and greatest independence for people receiving the services. The Department of Health’s 1992 Child Abuse Guidelines for Health Services set standards for preventing and responding to abuse.[74]

106. From 1996, most people in the care of health and disability service providers were also entitled to services that met the standards in the Code of Health and Disability Services Consumers’ Rights. There were limitations on the right to informed consent for some people who were considered unable to do so or where compulsory mental health treatment was ordered.[75] The standards in the code focused on the rights of people in care, including:

a. the right to be treated with respect
b. the right to be free from discrimination, coercion, harassment and exploitation
c. the right to dignity and independence
d. the right to make an informed choice and give informed consent (although people subject to a compulsory order were specifically excluded from this right).[76]

Ngā paerewa atawhai i ngā takinga toko i te ora
Standards of care in social welfare settings

107. From 1957 until 1989, the Department of Education’s Field Officers Manual and its later versions (including the Social Workers Manual) acted as default standards of care for social welfare settings.[77] These documents were essentially a complete guide to social work for staff, describing in detail how they should carry out all aspects of their day-to-day work. They also contained guidance on best practice in social welfare settings including residences, family homes and foster homes, including:

a. a State ward must be medically examined before entering an institution[78]
b. State wards should be visited at least once every four months, and in person[79]
c. State wards were to be seen on the same day where concerns were raised about their safety “within the hour if possible”[80]
d. the basic physical requirements for secure units, like the need for the cell to be specially designed for that purpose and provide adequate light, ventilation, warmth and safety for the child detained[81]
e. an array of standards for when a State ward was placed in a secure unit, including standards relating to their physical, education and mental and emotional needs[82]
f. ill-treatment or neglect of a State ward was unlawful[83]
g. if a social worker suspected a person in care was being ill-treated or neglected, investigating this took precedence over all other duties[84]
h. if ill-treatment or neglect was suspected, regardless of evidence, the person in care should be examined as soon as possible by a doctor[85]
i. NZ Police should be informed of cases of cruelty, ill-treatment or neglect.[86]

108. The various iterations of the manuals made changes to some specific areas over time, for example in relation to corporal punishment. The 1957 manual allowed corporal punishment but discouraged it and said that in every instance it is used it should be reported to the District Child Welfare Officer and recorded on a punishment register.[87] The 1975 manual said corporal punishment could only be used as a last resort by the principal, assistant principal or senior housemaster / housemistress.[88] In 1984, the manual prohibited the use of corporal punishment altogether and this policy remained in following versions.[89]

109. In State-run foster homes and family homes, there were limitations on the use of corporal punishment from 1937, including that it could not be used on girls.[90] However, in 1950, policy stated that punishment administered by a mother in private “with an open hand or a plain light strap” for children under 12 years old was not forbidden, but “should be limited according to the age, physical condition, health and mentality of the child concerned, and preference is to be given to other forms of discipline”.[91] In 1990, the Department of Social Welfare explicitly said the use of corporal punishment by foster parents and family home caregivers was unacceptable.[92]

110. By law, only reasonable use of corporal punishment was allowed under section 59 of the Crimes Act 1961. This was repealed in 2007.[93]

111. There were crucial gaps in the manual and its iterations until the late 1970s:

“[there was] no guidance for staff on responding to a child in care alleging sexual abuse; no guidance about what to do if caregivers were alleged to be perpetrators of abuse.”[94]

112. In the 1980s, the Field Officers Manual was replaced by the Care and Protection and Youth Justice Handbooks. These handbooks typically included significant discussion about family group conferences and legal powers over children and young people. They also set out obligations about standards of care that were similar to the Field Officers Manual, such as:

a. when a child or young person was placed in the care of the Director-General of Social Welfare, a social worker should arrange for a general medical check-up as soon as is practicable. As a general rule, parental consent and the consent of the young person (when appropriate) to a medical examination should be obtained[95]
b. children and young people in care should be visited at least every two months, meetings must be face-to-face with the child or young person only[96]
c. all allegations of abuse by caregivers of a child or young person placed in their care by the Director-General must be investigated[97]
d. when abuse is alleged to have occurred in a family home, every child or young person in residence will need to be interviewed[98]
e. when the allegation relates to sexual or serious physical abuse the joint CYPFS/Police Sexual Abuse Team protocol must be followed.[99]

113. These manuals or handbooks were not legally binding on staff, institutions or on foster carers and in practice they were treated as guides.[100] The documents were confidential and people in care had no access to them, neither did their families, whānau and communities.[101] There were no legally binding standards of care until 1986.

114. From 1986, legislative standards of care were put in place for all social welfare residences (a residence established under section 364 of the Children, Young Persons and Their Families Act). The standards did not cover foster homes, family homes and third-party care providers although they received State funding.[102] The standards were explicit about the basic rights of people in care, like rights to information about their care and the regulations, rights to personal items, privacy, visits from family and whānau and others, rights to a grievance procedure and rights to education and recreation.

115. The 1986 regulatory standards also clarified what treatments were unacceptable. For example, children and young people could not be degraded or humiliated, corporal punishment / physical violence was prohibited and limits were placed on the use of searches and secure care.[103] These regulatory standards were expanded in 1996.[104]

116. From 1992, the Department of Social Welfare set standards of care for third-party care providers, like Moerangi Treks and Te Whakapakari Youth Programme, through service contracts and its business unit, the New Zealand Community Funding Agency who approved, funded and monitored third-party providers.[105]

117. The Department’s standards for third party providers were more focused on service delivery and processes than on a shared set of accessible standards of care. The standards were high level, requiring processes be in place relating to a broadly stated standard. For example, these are from the standards for third party providers in 1995:

“Standard 10: Provision of Care
All organisations have procedures which ensure that the care provided for children and young persons meets their individual needs for safety and nurture.

Standard 11: Discipline
Children and young persons are not physically punished, or disciplined, or treated in a way that is degrading or humiliating or causes unreasonable fear or anxiety. Alternative methods of discipline are employed.

Standard 12: Procedure for Complaints
All organisations have a policy for dealing with complaints about staff / care-givers, which is written, given and is explained to families and young persons.” [106]

118. From 1995, third party care providers were also required to have in place protocols for reporting child abuse to the Department of Social Welfare and NZ Police.[107]

119. Social worker visits to State wards were meant to be a critical intervention point to prevent and respond to abuse and neglect in care. Minimum visitation standards were set from 1957.[108] Evidence shows that the minimum visitation standard of at least once every four months was commonly breached. Many survivors said they either never received visits from social workers while they were in care, or they were visited much less frequently than once every four months.[109]

120. It was also a requirement for social workers to see State wards personally during their visits.[110] Many survivors said that when visits did occur, they were always in the presence of their caregivers and they were unable to speak to their social workers alone. Māori survivor Gina Sammons (Ngāti Kura), who was first placed in foster care at 2 years old, said she “had to hide under the bed so the social worker wouldn’t see my black eyes”.[111]

121. Breaches of face-to-face visit standards meant children and young people remained in abusive environments without the opportunity to disclose the abuse or neglect they were experiencing to the responsible social worker.

122. The Inquiry heard that some staff cut corners because of caseloads, either reducing the number of visits, or not visiting at all,[112] with some staff recording that they had complied with the Manual’s standard despite not doing so:

“I would sometimes ring families, rather than do a visit. I would, however, write up the phone calls as if it was a visit … my understanding is that senior staff ‘turned a blind eye to this practice’ … I would ring more than half of the foster parents and then visit when issues arose.”[113]

123. At the Inquiry’s State Institutional Response Hearing, Nicolette Dickson, Deputy Chief Executive of Oranga Tamariki, accepted these breaches of visitation standards were common experiences of survivors in care during the Inquiry period.[114]

Ngā paerewa atawhai i ngā takinga mātauranga
Standards of care in education settings

124. Between 1950 and 1989, there were no legislated standards of care specifically for schools, including special schools for Deaf students. Schools made their own decisions about how they wanted to treat people in their care, including to what extent they wanted to use physical discipline/corporal punishment.[115] Section 59 of the Crimes Act 1961 allowed teachers to use reasonable force to correct behaviour.[116] As explained in the Department of Education’s 1964 handbook:

“What is permissible in a public primary school is determined by the general law, by the bylaws of the local Education Board, and by such directions as may be issued by the Head Teacher to his staff. … The Head Teacher himself has full responsibility for formulating … the school’s policy on corporal punishment … the final decision is his.”[117]

125. Corporal punishment was permitted in education settings until 1990. The Department of Education told the Inquiry that it began suggesting to schools that alternative methods of correction be used from the early 1970s but did not advise stopping its use in schools until 1987. Corporal punishment was prohibited under law on 23 July 1990.[118]

126. From 1950 to 1989, blind, Deaf and disabled children generally did not attend mainstream schools.[119] Their parents were responsible for providing them with “efficient and suitable education”.[120] If they could not or did not, the State could direct their child to be sent to a special school or a similar institution.[121] Special schools could either be day schools or residential schools with boarding facilities.

127. For principals of residential schools, there was a 1986 Department of Education Handbook for them to follow.[122] This contained standards including section 2.4.3 which related to ‘timeout’ procedures. This allowed both exclusion timeout and seclusion timeout and detailed under what circumstances each would be appropriate. It gave permission for children and young people to be physically removed to go to timeout and noted that children should be released from timeout within three to four minutes, as long durations in timeout could be counterproductive.[123]

128. As part of the Education Act 1989, all children and young people who had special education needs had the right to enrol and receive education at State schools.[124] However, if the Secretary for Education was satisfied that a child or young person should receive special education, they could still direct their parents to enrol them at a particular State school, special school, special class or special clinic.[125]

129. After 1989, the board of trustees of a State or State-integrated school controlled the day-to-day management of schools.[126] There were no standards of care in the Education Act 1989, but the Minister could issue national education guidelines, which were a “statement … of desirable codes or principles of conduct or administration for specified classes or descriptions of person or body”.[127] The Minister used this statutory power to issue binding guidelines to boards requiring them to provide a safe physical and emotional environment for students[128] and a duty to operate in a fair and transparent manner.[129] It was then largely left to boards to decide how to implement this standard within their school.

130. After 1989, school hostels, boarding facilities and private schools continued to decide for themselves whether to adopt standards of care or not, although they were not legally required to and there were no penalties or consequences for not doing so.[130] For example, up until 2000, policies at Dilworth School in Tāmaki Makaurau Auckland were kept “confidential to staff” so students and parents were not allowed to see them.[131]

131. In 1997, the Ministry of Education issued Circular 1997/12 (The Responsibility of Trustees for the Personal Safety of Students in Schools) to principals of State and State integrated schools, chairpersons of boards of trustees of schools and proprietors of private schools. In it, the Ministry set out its views on the responsibilities of principals, boards, and proprietors for the personal safety of children and young people in their care.

132. The Circular emphasised the need for schools to act promptly on complaints of alleged abuse. It also reminded schools they should implement policies to ensure all children and young people were treated with dignity and respect, had their rights and needs met, and that staff were familiar with how to prevent, recognise and respond to abuse.[132]

Ngā paerewa atawhai i roto i ngā takinga whakatika, mauhere ā-ture
Standards of care in transitional and law enforcement settings

133. Throughout the Inquiry period, NZ Police relied on their General Instructions and related manuals for how they treated people in their care.[133] These Instructions and manuals were similar to the social welfare Field Officer Manuals, in that they were internal best practice guidance for NZ Police on how to do their job.[134]

134. The standards in the manuals were generally not explicit about preventing abuse and neglect of children, young people, or adults in risk in the care of NZ Police. Standards included:

a. extreme care was to be taken in interviewing anyone under 17 years of age; a parent or guardian must be present or promptly informed if not[135]
b. a parent, guardian, or teacher must be present when interviewing a child under the age of 14[136]
c. when a young person was arrested, they should not be kept in a lock-up unless safe custody cannot otherwise be provided[137]
d. immediate attention was to be given to a complaint that someone was in need of care, protection or control, with inquiries completed in the shortest time possible.[138]

135. People who were State wards in transitional and law enforcement settings were covered by the standards of care for social welfare settings, and these were referred to in the NZ Police Instructions and manuals.[139]

136. The Instructions and manuals were not a transparent set of standards of care that people in care, their families, whānau or communities were given or could access on request.[140] When Dr Oliver Sutherland asked for copies on behalf of the Auckland Committee on Racism and Discrimination in 1977, he was told by the Minister of Police:

“I do not consider these suitable material for public dissemination and accordingly your application is declined. However, you have my assurance that the instructions are adequate and should serve to preclude complaints [from people in the care of Police] in these areas.” [141]

137. The Inquiry heard that young survivors, several aged 14 years old, were picked up by NZ Police and questioned without the presence of any parent, guardian, or lawyer.[142] Multiple survivors said that they were interrogated with physical violence and coerced into confessing to crimes, in some cases which they did not commit.[143] Pākehā survivor Lindsay Eddy said:

“You’re dumbfounded as a kid – tired and hungry, in a cell for a day so you just confess to get out. They never told you about your right to have an adult present.” [144]

138. These actions by NZ Police were breaches of the standards in their General Instructions.[145] They were extreme and had serious consequences that shaped the lives of survivors. These actions led to admissions to boys’ homes, borstals and adult prisons, which survivors were left to navigate alone.[146]

139. Some survivors reported being kept in NZ Police cells, often overnight or sometimes up to weeks.[147] The NZ Police’s General Instructions stated that a young person should not be kept in a lock-up unless safe custody cannot otherwise be provided.[148] The Department of Social Welfare also had an active role to ensure young people were not held in police cells, as set out in their series of manuals. In some instances, child welfare officers did not do anything to assist young people in these situations.[149] In other instances, social workers were unable to find an alternative place for these young people to go.[150] In 1997, one survivor was kept “in police cells for 3 months as there were no beds available in youth detention centres”.[151]

Ngā paerewa atawhai i roto i ngā takinga pūnaha taurima ā-whakapono
Standards of care in faith-based care settings

140. Faith-based institutions were required to comply with general standards in law, such as those barring ill-treatment and neglect, sexual assault and corporal punishment, but there were no legislated standards of care specific to faith-based institutions. Care standards, if any, varied between faiths and between regions within faiths, and changed over time.

141. From 1950 to 1999, the Catholic Church did not have a consistent set of safeguarding policies that applied across its institutions. From the early 1990s, the Catholic Church started to implement safeguarding guidelines and protocols, formalising these documents from 2000. However, it was not until 2017 that the Catholic Church implemented a formal, consistent safeguarding policy.[152]

142. From 1950 to 1999, the Anglican Church did not have a nationally consistent approach to safeguarding people in its care. The Anglican Church accepted that it had a “significant systems failure, particularly around the protection of children and vulnerable people”.[153]

143. The Salvation Army did not have a dedicated safeguarding policy in place during the Inquiry period. It adopted an internal Child Protection Policy in November 2015.[154]

144. The Methodist Church did not introduce a national safeguarding policy until 2000,[155] despite operating children’s homes since 1913.[156] The Methodist Church told the Inquiry that the Synod and Conference appointed a board to administer each children’s home that was responsible for admissions and the resident children’s welfare. At the Inquiry’s Faith-based Institutional Response Hearing, Reverend Tara Tautari (on behalf of the Methodist Church of New Zealand) said:

“The Church did not have safeguarding policies and processes in place, and this led to unimaginable suffering of some children, young people and vulnerable adults.”[157]

145. The Presbyterian Church of Aotearoa New Zealand made certain behavioural expectations more explicit in its adoption of a code of ethics in relation to pastoral care in 1995. However, it has acknowledged that the code of ethics has not been consistently upheld and that breaches are not consistently reported. It accepted it needs to do more to educate members about its codes and to make clear requirements around reporting and must make more requirements relating to safety binding on every part of the church.[158]

146. As the assemblies are autonomous, the Plymouth Brethren Christian Church does not have or enforce any national policies or procedures on any matters of individual assemblies.[159] The church told the Inquiry that families are responsible for safeguarding their children, young people and adults in care and educating them about abuse. The church does not consider that there are any opportunities for abuse within its pastoral settings and claims there are no barriers to disclosing abuse.[160]

147. The Gloriavale Christian Community leadership told the Inquiry it has had child safeguarding rules and procedures in place from its inception, but these were never formalised into a written policy during the Inquiry period.[161]

148. Faith-based institutions could also be approved to be care providers under section 396 of the Children, Young Persons and their Families Act 1989. As discussed above in relation to the standards of care in social welfare settings, these care providers were assessed against a set of standards for service provision, with annual reviews to ensure the standards were maintained.

Ngā aronga atawhai tangata kīhai i āta tuhia, i kaupare rawahia rānei ki te taha
Individual care needs were often not recorded or were ignored

149. Some care settings had record keeping and data management policies regarding individual care needs in place,[162] however the Inquiry heard evidence that these policies were not always followed and did not require the ethnicity or cultural identity of people in care in care to be recorded.

150. Several survivors told the Inquiry that their ethnicity was misidentified, incorrectly recorded or not recorded at all.[163] This primarily affected Māori and Pacific survivors. Some survivors believed this was done intentionally and wondered if social workers did this because they thought they were all the same or thought it would make them easier to be placed with a foster or adoptive family.[164] Research has found evidence of “insufficient, patchy and poor-quality ethnicity data collection across State care institutions”.[165]

151. From the late 1980s, failures to accurately identify and record individual care needs often meant services or funding were not provided to the person in care despite their care needs and eligibility. These failures were compounded for people with undiagnosed disabilities and could result in harm, such as educational neglect, or a lack of an ability to communicate that abuse or neglect was happening.

152. In 1994, the State introduced the Needs Assessment and Service Coordination service. The purpose of this service was to identify the needs of disabled people and people experiencing mental distress and match these to standardised funding and services.[166] The foundational policy for the Needs Assessment and Service Coordination service identified that it should not treat disabled people as being sick, it should be culturally sensitive and be flexible and innovative.[167] However, during the Inquiry period the service was based on a medical approach to treating impairments rather than the holistic the needs of the person and their whānau.

153. While some people were provided with the right supports and care through the Needs Assessment Service Coordination service, some were not which increased their risk of abuse and neglect (for example, by not having the communication supports necessary to report abuse and neglect). Several reports were published in the late 1990s and early 2000s highlighting problems with the service, particularly for Māori and Pacific Peoples.[168] In 2003, the National Advisory Committee on Health and Disability would recommend the service be fundamentally redesigned because of its shortcomings in identifying and meeting the needs of disabled people and people experiencing mental distress.[169]

I takahia e ngā tikanga toko hinonga ngā paerewa
Institutional environments and practices breached standards

154. During the Inquiry period, many children, young people and adults were placed in large-scale psychopaedic and psychiatric institutions. Deaf and disabled people and people experiencing mental distress were also placed in specialist wards in general hospitals and in educational settings such as special schools, residential schools and occupational training centres. Institutional models of care, which included institutional environments and practices, were a feature of these care settings.

155. Institutional environments and practices were also present in other care settings, such as social welfare residences and family homes. Children, young people and adults in care during the Inquiry period had diverse care and support needs. The 1957 Field Officers Manual outlined the need for children to know they were “recognised as an individual, different from others, with a name and story” of their own,[170] alongside standards to support each person in care having their individual needs recorded and met, like individual medical or educational needs.

156. Despite the diversity of people across multiple care settings and their different needs, they experienced a heavily regimented one-size-fits-all model of care with the same form of care applied to everyone regardless of their age, gender, abilities, culture, needs and reasons for being in care.

157. Features of institutional models of care which contributed to abuse and neglect included:

a. rigid routines that people in care had little influence or control over
b. identical activities shared by people in care or groups of people in care
c. people in care having limited or no influence over who provided their care
d. a lack of control over day-to-day decisions, for example activities or mealtimes
e. a lack of choice about who they lived with
f. isolation or segregation from the community.

In addition, for disabled people in care the key feature of an institutional environment that contributed to abuse and neglect was a disproportionate or high number of disabled people living in the same environment.

158. In care settings with institutional environments and practices, conformity with rules, discipline and order were prioritised over the needs of people in care, described as an approach of “rules, power and control”.[171] Conformity was often enforced through harsh and abusive discipline.[172]

159. For some larger institutions, a strict one-size-fits-all routine meant they could rely on smaller staff numbers. The Inquiry heard that smaller staff numbers led to people in care losing their independence and individuality.[173]

160. An emphasis on conformity over individual needs resulted in standards of care being overlooked or ignored and people in care not receiving the level of care they needed, increasing the risk of abuse and neglect. For example, in its report to the Minister of Health in 1986, the Department of Health said:

“In most psychiatric hospitals in New Zealand the range of treatment options available is inadequate so that patients with very different needs are often treated in the same ward with the same programme … the lack of individualised assessment, treatment and rehabilitation programmes tends to lead to undue reliance on drug therapy and various forms of custodial care; and to seclusion.”[174]

161. In that same report, the Minister of Health was told there was a widespread lack of formal recognition of the cultural needs of people in psychiatric institutions, such as access to te reo Māori interpreters, rongoā practitioners or cultural support groups.[175]

I rarua ngā paerewa i te noho kikī me te hē o ngā wāhi tiaki
Standards were compromised by overcrowding and unsuitable facilities

162. Overcrowding and unsuitable facilities were another example of institutional environments and practices that compromised basic standards of care and contributed to abuse and neglect.[176] Overcrowding was common in psychiatric institutions, social welfare residences and in family homes.[177]

163. Many institutions had substandard physical environments. Buildings were outdated, poorly designed and inappropriate; with some social welfare residences lacking ground space for recreation and activities.[178] Institutional design that reflected military or prison environments was common at many residences, for example, barbed wire, heavily barred secure cells, high walls and open block sleeping quarters similar to secure cells.[179]

164. Overcrowding often led to compromised daily routines like reduced or absent oversight, lack of individualised care and limited activities. Many people in overcrowded and unsuitable environments suffered abuse and neglect, including:

a. sexual abuse
b. a lack of privacy and dignity through open toilet, washing, and sleeping areas
c. compromised personal hygiene and dental and medical care
d. no access to clean personal items like clothes and shoes
e. limited warm clothing and bedding
f. generally unsanitary living conditions.[180]

165. Geographically isolated facilities could increase the risk of abuse and neglect by creating opportunities and cultures of total control with limited outside influence.[181]

166. Father Timothy Duckworth, Provincial of the Society of Mary, believed that the militaristic style of schooling at Hato Pāora College near Aorangi Feilding was, like other male boarding schools, intensified by its geographic isolation:

“Hato Pāora was operated in a militaristic and masculine fashion, which would have emphasised conformity, strength, and toughness. I consider this a ‘macho’ culture. This was not unusual in a boys’ boarding school, but I believe this may have been more pronounced at Hato Pāora due to its small size and isolated location.”[182]

167. Isolated facilities could also lead to staff focusing on control and surveillance, which contributed to them becoming desensitised to the needs of people in their care.[183] Isolated areas within facilities could become areas where abusers would have unsupervised access to people in care and their abuse hidden from sight.[184] Isolated facilities could also make it difficult for families and whānau to connect with and visit their loved one in care, a critical protective and safeguarding factor.

168. Secure units were an unsuitable physical environment that contributed to the abuse and neglect of children, young people and adults in care. While there were standards in place from 1957 in social welfare settings on the physical environment of secure units, evidence shows these were often not followed. At the Inquiry’s State Institutional Response Hearing, Chappie Te Kani, Chief Executive of Oranga Tamariki, agreed that the history of treatment of children in solitary confinement was “inhumane”.[185] Many institutions used solitary confinement and similar restrictive practices. Secure units were also environments where people in care would experience physical or sexual abuse. These were still in use in 1989, despite being heavily regulated.[186]

169. Age mixing was a common feature of social welfare settings including in residential care, family homes and foster care, with younger children routinely placed with much older children or young people. This increased the risk of peer-on-peer violence and sexual abuse. Māori survivor Te Aroha Knox (Ngā Puhi, Tainui) said she was “constantly surrounded by older children” in one family home when she was about 10 years old, and that “they were men really”.[187] One night she was raped by an 18 year old boy and the next night a 16 year old boy attempted to rape her. She said she was “completely unsafe in that family home”.[188] Age mixing also exposed younger children to dangerous behaviours of their older peers, for example violence, crime, drugs and alcohol.

170. In 1969, the principal of Miramar Girls’ Home in Te Whanganui-ā-Tara Wellington became increasingly concerned at the problems arising from young girls in need of care being cared for in the same facilities as difficult teenage girls who were on remand. The principal recalled three instances where children as young as 4 years old were sexually assaulted by teenage girls. He also worried about the effect on younger children of the “frightening hysterical type behaviour” exhibited by some teenage girls.[189] The Superintendent was made aware of these negative aspects of mixed aged and dual-purpose care and noted that, while the policy was “undesirable”, the Child Welfare Division was “still a long way from rectifying this anomaly”.[190]

171. Gender mixing of children and young people in residences and institutions became more common in the late 1980s when many of the large single sex residences closed. A Department of Social Welfare report from 1986 on sexual abuse in residential institutions showed there were differing views on the risks of sexual abuse in gender mixed residences. The report attached an opinion from Dr Miriam Saphira CNZM supporting single sex facilities but concluded that “sexual abuse occur[s] in heterosexual and mono-sexual institutions”. It noted that “mono-sexual institutions are not necessarily any safer” but recommended “there should be choices for male and female sexual abuse victims” who may wish to be placed in a single sex facility. The report identified that all residential institutions were responsible for safeguarding against sexual abuse.[191] However, evidence indicates that safeguarding against sexual abuse was not adequate.[192]

172. The mixing of children and young people in social welfare institutions also created an environment where there was heightened risk of abuse and neglect through exposure to violence, criminal behaviours and other influences. The risks were described by the principal of Ōwairaka Boys’ Home in Tāmaki Makaurau Auckland in 1967:

“…the mixed function of the Home creates major difficulties. The home is required to absorb a large number of cases on warrant and remand as well as cases where short term training and residence is required before placement. The result is that neither aspect of the work can be undertaken with success”.[193]

Kīhai te tauira mo ngā pūnaha taurima i noho tika me ngā paerewa atawhai
Punitive care model was inconsistent with standards

173. Institutions that adopted a “punitive model”[194] commonly drew on elements of cultures within the prison system and/or military and frequently involved physical, violent treatment of people in care. Former social worker Mr PY told the Inquiry that the secure units at both Kohitere Boys’ Training Centre in Taitoko Levin and Ōwairaka Boys’ Home in Tāmaki Makaurau Auckland were cell blocks and that:

“[t]o a young person Ōwairaka would have been seen like a prison. Being placed in the Secure Unit on admission and then potentially later for misbehaviour would only have reinforced this”.[195]

174. New Zealander Mr BY, who was placed in Kohitere Boys’ Training Centre in Taitoko Levin when he was 15 years old, told the Inquiry:

“There should not be a jail mentality in care facilities. It needs to be remembered that a care facility is a children’s home. Some of the children may have done stupid things, but they are still children.”[196]

175. Survivors who spent time in corrective training described it as “military style training,”[197] and told the Inquiry that it was designed to “scare the shit out of us for three months and get us back on the straight and narrow except it didn’t really work”.[198] Pākehā New Zealander Mr TL, who was placed in Rangipō Prison Farm corrective training facility near Tūrangi when he was about 17 years old, believes that he and the other trainees were part of a “failed experiment”,[199] explaining that:

“CT [corrective training] was a three-month youth justice sentence which was introduced in 1985 as a replacement for borstal. It was designed as a type of ‘bootcamp’ for young offenders aged 16 to 19 years. I think it was supposed to ‘scare us straight’. From what I understand the concept of CT was quickly abandoned as the reoffending rates were very high.

The focus of CT was entirely on ‘breaking’ trainees using practices such as name calling, swearing, punching, kicking, shouting, physical exercise beyond the point of exhaustion, sleep deprivation, humiliation, setting up bullying between trainees and poor living conditions”.[200]

176. Mr TL said that “[a]bsolutely no effort” was made to address the reason for the offending which bought young people to corrective training, or to provide skills or support so that they could make positive changes in their lives when they left. [201] This experience was echoed by other survivors,[202] with one survivor noting that the programme “didn’t stop people from going to prison later”.[203]

177. Instead of reforming or rehabilitating them, survivors told the Inquiry that it “made me worse, not better”;[204] that “[a]ll the beatings and bashings only made you harder and angrier”;[205] and that “we learnt how to fight better, how to run more quickly from the police and be fitter, stronger young men.”[206] They also told the Inquiry that corrective training put them and others on a path towards more criminal offending and prison.[207]

178. Between 1957 and 1965, 67 percent of all borstal trainees were reconvicted within two years of their release.[208] In 1980 the Minister for Justice publicly acknowledged that these rehabilitative programmes had not fulfilled their objective. The Minister also accepted that reoffending rates showed these had not succeeded in reducing reoffending.[209]

179. Tamariki and rangatahi Maōri made up the majority of people in borstals or corrective training facilities during the Inquiry period.[210]

180. In 1981, the Penal Policy Review Committee noted that detention centre training had not worked and had a reoffending rate of over 70 percent.[211] Their report highlighted concerns that the hard physical training programme was completely inappropriate for many young people being sent there, and that:

“[F]or the underprivileged, inadequate youth who can barely cope, this sentence may infringe the United Nations prohibition of cruel and inhumane treatment”.[212]

181. Studies on boot camp programmes that became popular as a juvenile correctional sanction throughout the United States in the 1980s found boot camps alone “do not have an effect on participants’ odds of recidivism”.[213] Critics have argued “that the structure and process of boot camps are ideologically inconsistent with rehabilitative treatment”. Reasons for this include that boot camps do not “target the causes of delinquency”, may “impede rehabilitation by relying solely upon negative reinforcement”, and their structure is one where “adult bullies are given unfettered power over vulnerable charges”, which can encourage physical abuse and neglect.[214]

182. Professor Elizabeth Stanley told the Inquiry that:

“State workers used a host of violent punishments, isolation techniques and damaging medical treatments to make children comply with their demands. Wrapping it up in the language of rescue, treatment or discipline, we somehow give this violence legitimacy.”[215]

I takahia tonu ngā paerewa atawhai
Standards of care were routinely breached

183. Standards of care were routinely breached throughout the Inquiry period. In many institutions, residences, family homes and foster homes, schools, hostels, and transitional and law enforcement settings, breaches of standards of care were serious and unlawful. For example, the Inquiry has found abuse and neglect occurred across all care settings throughout the Inquiry period despite being unlawful. Despite sexual abuse being unlawful in all settings throughout the Inquiry period, the Inquiry found sexual abuse was a common form of abuse in care, with children aged 10 to14 years old enduring high levels of sexual and physical abuse. Some further key examples of departures from standards are discussed below.

I hē te whakanoho tāhanga, weherua, te tiaki ā-here hei tikanga whiu
Solitary confinement, seclusion and secure care wrongfully used as punishment

184. Some settings had standards that limited the use of solitary confinement, seclusion or secure care. For example, under the Mental Health (Compulsory Assessment and Treatment) Act 1992 it was only to be used if necessary, where necessary, and for as long as it was necessary, for the care or treatment of the patient or the protection of other patients.[216]

185. Under Department of Social Welfare standards from 1957, it was generally only to be used as an emergency procedure. Under the Children and Young Persons (Residential Care) Regulations 1986, it was not to be used for punishment.[217] The Department of Education set guidelines on the use of timeout in residential schools in 1986, including that it should not be used for longer than a matter of minutes.[218] In addition, the Crimes Act 1961 still sat across every care setting and could come into effect if its use amounted to neglect endangering the life of a person or permanent health of a person.[219]

186. Despite these limits on the use of solitary confinement, seclusion and secure care, the Inquiry found survivors commonly reported the misuse of solitary confinement or seclusion, that there was over-use of seclusion in residential care, and wrongful use of solitary confinement in psychiatric facilities.

I takahia tonu ngā paerewa rongoā, i ētahi wā he takahi hoki i te ture
Medical standards were frequently breached, at times unlawfully

187. Despite a range of medical standards being in place, the Inquiry found some children, young people and adults in care experienced over-medicalisation, lobotomies, sterilisation, invasive genital examinations, experimental psychiatric treatments without informed consent, electric shocks and injections of paraldehyde as punishment, which exposed some patients to unreasonable medical risks.

188. Medical certificates were required for all State wards before admission to a social welfare residence to ensure their medical needs were known to staff and carers,[220] “but this system frequently fell down”.[221]

189. Many people in care were medicated for long periods without the necessary medical reviews:[222]

“Significant numbers of patients continue to be given drugs for lengthy periods without review. Such lack of review of individual treatments is of particular concern as many of the drugs, if given over prolonged periods, are capable of producing serious side effects.”[223]

190. Survivors from St Mary’s Home for Unwed Mothers in Tāmaki Makaurau Auckland experienced inadequate support during pregnancy and medical neglect during childbirth.[224]

191. Breaches of health care standards were sometimes outside the control of the institution. Institutions could go for long periods with no visits at all from doctors or health specialists when they were not available. For example, Campbell Park School in Waitaki had no visits for seven months in 1971, Hokio Beach School near Taitoko Levin had no visits for two years from 1973 to 1975, Holdsworth School near Whanganui had no visits in 1980 and Epuni Boys' Home in Te Awa Kairangi ki Tai Lower Hutt had no visits in 1981.[225]

He pūputu tonu te kino o ngā whiu patu me te wepu tangata
Physical, corporal punishment was often severe

192. Between 1950 and 1990, standards on corporal punishment varied across settings and was unlawful in all care settings from 1990. In Department of Social Welfare institutions, corporal punishment was discouraged from 1957 and prohibited in 1984.[226] In foster homes, its use was limited from 1937 but the Department did not ban it in policy until 1990 and under law it was not banned in the home environment until 2007.[227]

193. In education settings, corporal punishment was prohibited under law in from 1990 but began to be phased out in policy before this time.[228] The Inquiry heard that some faith-based schools kept their own policies allowing the use of corporal punishment after 1990.[229]

194. Before any setting prohibited corporal punishment, standards made it clear that it was only to be used in reasonable circumstances, without weapons and as a last resort. This was not the experience of most survivors. Teachers, foster parents, principals, supervisors and staff members used physical force that went well beyond what could be justified under the standards of the time, whether or not it was explicitly prohibited.

Ko ngā kōtiti kētanga i roto i ngā tari Kāwanatanga te pūtakenga mai o te takahi i ngā paerewa
Government agency confusion led to serious breaches of standards

195. Evidence before the Inquiry highlights that government agency confusion led to serious breaches of standards. At times, confusion amongst government agencies about the extent of their statutory powers and how these overlapped with the powers of other agencies resulted in serious breaches of standards.

196. In most cases, the confusion was between Department of Social Welfare staff and other government agencies or NZ Police.[230] In one example, this resulted in a 15 year old boy being unlawfully placed in Lake Alice Hospital and subjected to unconsented medical treatment, including electric shocks.[231]

197. In 1987, the Department of Social Welfare realised it had been using secure units unlawfully as a result of “a defect” in their empowering legislation, which had come into effect in 1983.[232] Before 1983 there had been no specific legislative provision for the Department to operate secure units and confine children and young persons in secure care despite them having been used for over 20 years by that point.[233] However, this was subsequently clarified by another law change in 1996, prescribing when secure care could be used for children and young people in residences.[234]

He akonga i kitea he mea i panonihia i roto i ngā paerewa atawhai
Lessons identified and changes made to standards of care

198. It is difficult to say that the State learned that some practices were harmful during the Inquiry period. For example, from the outset of the Inquiry period, the State knew abuse and neglect were unlawful. The State also knew early on during the Inquiry period that excessive corporal punishment was wrong, and it was aware that alternative forms of punishment were in some cases preferable.[235] However, it took until 1990 for the State to legislate to abolish corporal punishment.

199. The State was slow to make legislative changes to prohibit practices that harmed children, young people and adults in care, and slow to act when it knew harmful or unlawful practices were happening.

200. From 1957, the State demonstrated it knew what components of good standards and practice could look like through the Field Officers Manual and subsequent versions. However, these standards were located in staff manuals for most of the Inquiry period; were generally inaccessible to people in care, their families, and whanau; were process-driven (rather than rights or person-driven); and lacked any references to te Tiriti o Waitangi or the human rights of those in care. They were also inconsistently applied between individual staff, foster carers and institutions, and people were rarely accountable for failing to follow the standards.

201. Standards of care were rarely provided for in legislation or regulations and, when they were, they were only applied to certain parts of care settings (like social welfare residences having regulated standards, compared to faith-based private schools that had none). This meant people in care experienced differing levels of standards and care providers had differing obligations to those in their care.

202. For most of the Inquiry period, there was also little evidence of effective collaboration with families, whānau and people with lived experience of care in the development of standards of care.

203. From about 1986 onwards, the State made changes to reflect it had learned that institutions needed legislative direction from the State on standards of care. The State introduced comprehensive legislative standards in 1986 for children and young people in State social welfare residences,[236] although these standards did not apply to children and young people in foster care or social welfare facilities run by third party providers. Standards did not apply to children, young people or adults in care in other settings.

204. The State did not legislate to give effect to te Tiriti o Waitangi as part of standards of care, even though those rights were directly relevant to tamariki, rangatahi and pakeke Māori in care.

205. The State did not progressively introduce human rights protections into care-specific legislation, even though the Crown had progressively increased its international human rights commitments over the Inquiry period.

206. In 1992, the State introduced the Mental Health (Compulsory Assessment and Treatment) Act to establish basic standards of care for patients who were assessed and treated under compulsory mental health orders.[237]

207. Faith settings learned of the harm of abuse and neglect but generally failed or were slow to implement standards to safeguard against it. Some faith-based schools learned of the harm of corporal punishment but maintained standards that allowed for its use, even following its legislative abolition.