CCHR, a mental health industry watchdog, says a New Zealand Inquiry finding of 200,000 children and vulnerable adults tortured in psychiatric and behavioral institutions mirror similar abuses uncovered in the U.S.

By CCHR International
The Mental Health Industry Watchdog
July 26, 2024

CCHR International praised a New Zealand inquiry’s report revealing decades of appalling abuses in psychiatric, behavioral, and disability institutions. Released on July 24 by the Royal Commission, the highest-level inquiry in New Zealand, the findings culminate a six-year, $101 million investigation that uncovered a Kafkaesque nightmare of individuals being tortured under the guise of mental health care.[1] The New York Times detailed, “The abuse included sexual assault, electric shocks, chemical restraints, medical experimentation, sterilization, starvation, beatings,” according to the Royal Commission report.[2]

The NZ Prime Minister Christopher Luxon told survivors, many of whom watched his speech in Parliament: “The State was supposed to care for you – but instead many of you were subjected to the most horrendous physical, emotional, mental, and sexual abuse.” He added: “People in positions of authority who you should have been able to trust – failed you in the worst possible way. When you tried to speak up, those same people turned a blind eye, they covered it up, and they prevented you from seeking justice for far too long.” The survivors were finally told what they had been waiting five decades to hear: “You are heard and you are believed.”[3]

CCHR in NZ played an integral role in supporting the survivors, championing their cause since 1977. It initially documented the electroshocking of children’s legs and genitals by a psychiatrist at the now-closed Lake Alice Psychiatric Hospital.[4]  Mr. Luxon stated, “The Government is formally acknowledging that the experiences of some children and young people at Lake Alice Hospital did amount to torture.”[5] Compensation could reach $1.2 billion (NZ$2 billion), or more.

Radio New Zealand reported that CCHR said, “The government needed to make sure the abuse uncovered by the Royal Commission of Inquiry did not happen again.”[6] CCHR made extensive submissions to the Inquiry, for which Judge Coral Shaw, Chairperson of the Royal Commission, expressed gratitude, acknowledging CCHR’s “extraordinary efforts” on behalf of the survivors.[7]

Jan Eastgate, President of CCHR International, headquartered in Los Angeles, stated that the report is one of the most monumental ever in recognizing and condemning psychiatric abuses in the 46 years she has worked with CCHR exposing these, adding it is “significant vindication for all those who revealed the truth about the abuses.” She added that the report “reflects the systemic abuse occurring not only in New Zealand but also in the mental health field in the U.S. and globally.”

While living in Australia in the late 1970s, Eastgate worked with the NZ CCHR chapter to expose the atrocities at Lake Alice Psychiatric Hospital. She warned that some of the findings in the current report mirror those recently reported by the U.S. Senate Finance Committee after its two-year investigation into youths being sexually abused, beaten, drugged and restrained in behavioral institutions here. She also pointed to the continued use of an electroshock device for behavior modification at a facility in Massachusetts that should have been banned years ago and also amounts to “torture.”

The Royal Commission report, “Whanaketia – Through pain and trauma, from darkness to light,” details cruelty, violence and abuse that were embedded in the way social welfare settings functioned. Survivors described being sexually abused while physically or chemically restrained. Staff sexually assaulted patients. A 16-year-old was sexually assaulted by her psychiatrist to whom she became pregnant and was given an abortion without her knowledge. There were also forced hysterectomies. [8]

Medical experimentation occurred, and one expert testified that drug research was conducted, recounting a meeting with psychologists, where one researcher callously chuckled and said: “It’s great because the retards are one step higher than rats.”

Lake Alice staff members gave drugs to male patients that left them impotent; electroshock treatment was given to “shock the gayness” out of one boy; women were electroshocked. According to one study electroshock was given “beyond the stage of gross confusion, to a stage where there is temporary dementia, with complete disintegration and loss of personality.” 

The Royal Commission made 138 recommendations, many of which CCHR and survivors had stressed were needed for establishing effective complaints mechanisms and ensuring criminal and civil accountability. These measures had previously been unavailable due to a now-acknowledged cover-up and a culture of disbelieving patient complaints.

The Inquiry recognized the international legal right to be free from torture and cruel, inhuman or degrading treatment or punishment. Those subjected to breaches of this have a right to effective redress. Acts of abuse and neglect of this nature may constitute violations of criminal and civil law. Investigating these acts, holding those responsible to account, and providing redress to survivors is the right thing to do, according to the findings.

The Royal Commission called for a ban on all types of inhuman treatment, humiliation, or degradation of one person by another, and for the government to take steps to ban pain compliance techniques in any care setting for children, young people or adults in care. The government should also prioritize and accelerate work to minimize and eliminate solitary confinement (seclusion) in all care settings as soon as practicable.

The Prime Minister encouraged all New Zealanders to read the report to understand the abuse the survivors suffered and the lifelong impact it has had on their lives. “I will never lose sight of what you have endured to bring the truth to life,” he said, closing with an excerpt from a karakia [Māori prayer used to invoke spiritual guidance and protection] written by Waihoroi Shortland who worked on the Inquiry:

To you upon whom this inquiry has been centered,
Resolute in your pursuit of justice
Relentless in your belief for life
We have only our highest regard and respect,
May your peace of mind be assured.”[9]

After Mr. Luxon spoke, in a heartrending move, survivors stood and spontaneously sang a Māori song about love and unity.[10]

The Royal Commission called for apologies from government and private agencies, including the Royal Australian and New Zealand College of Psychiatrists and Medical Council of New Zealand.

Eastgate said similar apologies are needed from psychiatric organizations worldwide, including in the U.S., because the horrors suffered in NZ have also been documented in many countries. She emphasized that the Inquiry’s recommendations apply globally and reiterated CCHR’s call for a prohibition on all coercive psychiatric practices to protect lives.

NEW ZEALAND INQUIRY REPORT FINDINGS

Those from the Indigenous Māori community were especially vulnerable to abuse, the report found.

The Royal Commission respectfully detailed both their spiritual beliefs but also the impact of institutional abuse not just on the person submitted to the abuse, but the entire family and community. For example:

• Mauri is a life force or vital essence that is present in all living things. It is “a material symbol of a life principle, source of emotions – the essential quality and vitality of a being or entity.” Mauri is interconnected with a person’s wellbeing or state of wellness. Their mauri is affected if their mental, physical, emotional, or cultural health declines or is negatively affected. (Point 248, page 140)

• A person dies when their mauri is extinguished. The mauri of survivors of abuse who died before or during this Inquiry has been completely extinguished upon their death. While their health and wellbeing cannot be restored, it is important to recognize the collective impact of the abuse on the mauri of their whānau [extended family], hapū [tribe or clan], friends and other survivors. (Point 250, page 141)

• Wairua is the non-physical spirit or soul of a person. In the Māori worldview, all things, both animate and inanimate, have whakapapa and wairua. A key difference between wairua and mauri is that the wairua is not extinguished at death, but stays in the body until it is released, when it can cross into the spiritual realm and continue forever. (Point 251, page 141)

The 3,000-page report, which includes numerous references to CCHR’s submissions, endorses recommendations CCHR made regarding international treaties to combat torture, and criminal accountability for abuse. To first summarize some of these:

• There is an international legal right to be free from torture and cruel, inhuman or degrading treatment or punishment. Those subjected to breaches of this have a right to effective redress.

• Such acts constitute violations of criminal and civil law.

• A ban on all types of inhuman treatment, humiliation, or degradation of one person by another. 

• Ban “pain compliance” [behavior modification] techniques in any care setting for children, young people or adults in care.

• Eliminate solitary confinement (seclusion) in all care settings.

• Close care and protection residences that perpetuate institutional environments and practices that led to the historical abuse and neglect in care.

• Establish a better and more accountable complaints system, including legislation to create a mandatory reporting system where professional bodies (that covered up complaints for years) must also mandatorily take disciplinary action and report criminal matters to the police. .

• Give police more powers to investigate and prosecute. Police should establish a specialist unit dedicated to investigating and prosecuting those responsible for historical or current abuse and neglect.

• All professional registration bodies need to report all complaints, disclosures or incidents to the government’s Care Safe Agency, whether substantiated or not substantiated.

• Survivors should be compensated.

Breakdown of Issues Raised

• All human beings have intrinsic worth, inherent dignity and certain inalienable rights because they are human. Upholding the principle of human dignity has at least five aspects:

o banning all types of inhuman treatment, humiliation, or degradation of one person by another person
o protecting bodily and mental integrity
o ensuring the possibility of individual choice and the conditions for each person’s self-fulfillment, autonomy or self-realization
o recognizing that protecting peoples’ self-determination, identity and culture may be needed to protect personal dignity, and
o creating the conditions to ensure each person can have their essential needs met. (Point 276, page 148)

• There must be accountability for human rights breaches. To achieve accountability, the State must ensure effective monitoring, prompt investigations and remedies. Victims of human rights breaches must have effective redress from whoever is responsible for upholding the rights (duty holders). Depending on the right breached, victims can be individuals or collectives, and redress can be individual or collective. (Point 288, page 152)

• There is an international legal right to be free from torture and cruel, inhuman or degrading treatment or punishment. Those subjected to breaches of this have a right to effective redress (Point 122, page 86). Acts of abuse and neglect of this nature may constitute violations of criminal and civil law. Investigating these acts (including the systemic factors that contributed to these occurring), holding those responsible to account, and providing redress to survivors is the right thing to do, according to the findings. (Point 123, page 87)

• The use of electric shocks and paraldehyde as punishment at the Lake Alice Child and Adolescent Unit met the definition of torture as stated by the Solicitor-General. (Point 120, page 86)

• Cruelty, violence and abuse were embedded in the way social welfare settings functioned and were ritualized in survivors’ day‑to‑day lives. (Point 439, page 148)

• Children, young people and adults in care experienced the over‑use of seclusion, over‑medicalization, lobotomies, sterilization, invasive genital examinations and experimental psychiatric treatments without informed consent. (point 75 f, page 50, and page 59)

• Some babies, children, young people and adults in care experienced extreme abuse and neglect multiple times. Many experienced more than one type of abuse or neglect. The compounding effect of these impacts has led to substantial trauma in the lives of survivors and of their whānau [extended family]and community. (Point 100, page 46)

• Survivors described being manipulated and threatened, particularly when they were being physically, sexually and spiritually abused. In many instances, abusers used manipulation and threats to exploit, control and silence survivors. (point 72, page 38)

• Staff pulled children’s hair, punched, slapped, and kicked them. Survivors described being dragged by staff, wrestled to the ground, thrown into walls, and put into headlocks. (Point 444, page 149)

• Staff not only physically abused residents themselves, but often encouraged, instigated or organized peer‑on‑peer abuse. The Inquiry heard staff would often arrange fights between children and young people, usually to punish one of them. Many survivors described a culture where children and young people were expected to resolve issues through violence (Point 447, page 150)

• Survivors described being sexually abused while physically or chemically restrained, when receiving treatment, and when heavily medicated. (Point 837, page 248)

Demand for Apologies

• The commission called for apologies from government and private agencies, but also: the leaders of relevant professional bodies, including the Royal Australian and New Zealand College of Psychiatrists, Medical Council of New Zealand, Aotearoa New Zealand Association of Social Workers, and New Zealand Nurses Association.  (page 77)

Drugging

• Medicalization overlaid much of the abuse perpetrated in these institutional settings, allowing for the justification of abusive and dehumanizing practices, and enabling resources within the medical environment, such as medication, equipment and spaces for solitary confinement [seclusion], to be used in harmful ways. (point 679, page 212)

• Māori survivor Walton James Ngatai‑Mathieson (Ngāti Porou), who had been in Lake Alice Child and Adolescent Unit told the Inquiry that staff members gave drugs to male patients that left them impotent, and that a staff member gave him pills that chemically castrated him, saying: “I was given a ‘blue pill’ when I was older at Lake Alice. I understood this was to make sure I could not get anyone pregnant. I called it the ‘kill cocker.’ This belief was confirmed by what other patients also told me.” (Point 773, page 233)

Electroshock Treatment

• Māori survivor Joshy Fitzgerald (Te Arawa), who was at Tokanui Psychiatric Hospital as a teenager, described how staff knew he was gay and tried to “shock the gayness” out of him: “And then while I was there, I … had three lots of electric shock treatment and I was about 15.”  Joshy said no one talked to him about being diagnosed with anything, but that once he mentioned he was gay “everything changed”: “That’s when they did the electric shock treatment. I wasn’t diagnosed with anything that I can remember… I received the electric shocks because I was gay. I remember when I was walking to get the first shock done and asked, ‘Where are you taking me’? The male staff member said, ‘We’ve got to get this gay out of you.’ … I don’t remember a lot after the ECTs. It’s like it wiped my memory. The three or four months before the ECT, I don’t have any memory.”  (Point 764, page 231)

• A paper published in the 1958 New Zealand Medical Journal described the daily treatment of 25 women over the previous eight years in New Zealand who were “given ECT beyond the stage of gross confusion, to a stage where there is temporary dementia, with complete disintegration and loss of personality.” The author stated: “After a week or more, mental confusion and imperception occur, so that the patient does not recognize objects, persons and places. There is complete poverty of imagination…It is important at this stage that the treatment be continued until there is complete loss of personality. The patient may show gross regression until she curls up into the antenatal position.” (Point 790, page 238) 

Sexual Abuse and Forced Abortions/Hysterectomies

• In a 2004 report provided to the Minister of Health, a total of 24 cases were identified of women with learning disabilities who received hysterectomies from 1997 to 2000. The report noted that of these cases, 16 of the patients received hysterectomies to manage excessive and frequent menstruation, the average age of these patients was 15 years old. (Point 777, page 235)

• Survivor Ms. GI told the Inquiry that her sister, who was in a psychiatric institution, woke up to find that she was undergoing an abortion: “She said that she did not want the abortion, but one night she had woken up and they were operating on her to abort the baby. I am certain that this put her into a deeper depression.” (Point 781, page 236)

• Survivor Steven Storer told the Inquiry that a staff member at Oakley Hospital sexually abused him while he was in a dazed state. Sexual abuse for survivors in these settings included indecent exposure, forced oral sex, and being repeatedly raped. (Point 837, page 248)

• Christina Ramage testimony: At 16 years of age, she was sent to Carrington psychiatric hospital in 1972, where she was electroshocked without anesthetic. “It was a known thing that the male nurses at Carrington were university students working for wages in the semester break, so a lot of them were totally untrained. In the female ward, women were there to be used for sex or assault….” She detailed being grabbed by two young male nurses, taken into an area behind doors where the straitjackets were kept, and was placed in one. “I was confused and afraid; I didn’t know what I’d done wrong, and I was terrified of whatever was going to happen. They laughed and joked. ‘Nobody can see us here,’ one said. They pushed me onto the ground…I struggled uselessly to get out of the straitjacket even though I knew I couldn’t. I closed my eyes, I was overwhelmed and despairing. As one raped me, the other would say, ‘Hurry up, hurry up.’ I was raped by both of them.”

She was also sexually abused by a psychiatrist. “A nurse took me to a very small room and the psychiatrist locked the door. He asked me a few questions. One of them was, ‘Do you like sex?’ I thought he’d find something wrong with me if I said no, so I said yes. The nurse took me to the examination bed and left the room, and the psychiatrist took my underwear down and raped me…A few months after the psychiatrist had raped me, a nurse took me to a room [and] told me to get on the bed, and suddenly everything went dark. The next thing I knew, I was awake. ‘It’s okay, you haven’t got a baby anymore,’ a nurse said. I realized I had been given an abortion following the rape by the psychiatrist. I think this is one of the most criminal aspects of my time at Carrington. It still haunts me today…I was given 10 rounds of electric shocks, six shocks per round…ECT was often given as a form of punishment. I had to get onto the bed and the nurses would put a cloth in my mouth while they held me down. The doctor would say, ‘are you ready’ and flick the switch on the grey ECT box… It is encouraging that, after 37 years in my case, a Royal Commission of Inquiry has finally taken steps to seek to uncover the harrowing stories of many individuals who were in care. It’s long overdue. I’ve spoken out for the people who are currently in psychiatric wards, and for those in the future. My experience shows that there is always hope.” (Pages 125-128)

Solitary Confinement/Seclusion

• Solitary confinement, sometimes referred to as ‘seclusion,’ was used as punishment, behavioral ‘management’ and even convenience in some large‑scale institutional settings. Solitary confinement was used as part of the daily routine in some of these institutions and the Inquiry heard from survivors that its use was psychologically and physically abusive. (Point 793, page 239)

“Wilderness” Programs for Youths

• Third‑party providers set up programs that they designed to provide for the rehabilitation of youths. The programs offered activities such as wilderness training, allegedly designed to develop competence in the child or young person’s ability to cope, learn and experience a positive lifestyle with outdoor pursuits and life skills. However, children and young people placed in these programs suffered neglect and often extreme physical, sexual and psychological abuse. The Inquiry heard many examples of violence from survivors who experienced abuse from third‑party providers, some involving guns or death threats. One staff member used extreme scare tactics:

“He made us dig our own graves. The holes were deep, and we were made to get in and lay face down. We weren’t allowed to look, and he threatened to shoot us. The supervisor started shooting into the air and we were screaming, begging for our lives and freaking out. It was horrifying. When we tried to get out of the holes, he would just kick us and beat us back in.”  (Point 501, page 164)

A Department of Social Welfare report into complaints of mistreatment at Moerangi Treks noted that survivors’ allegations of being hit in the head, choked with a rope and hit in the face with a gun “have been corroborated by more than one of the clients on the program.”

Survivor Mr. UE described the physical abuse a “tutor” subjected him to on his first day: “…he stood up and started to punch me in the head constantly until I was concussed, losing my balance.” (Point 504, page 165)

The report’s conclusions included: “There is a substantial amount of evidence to suggest that physical abuse is a regular occurrence at Moerangi Treks. The abuse is systematic and harsh, and serious injuries have occurred as a result.” (Point 506, page 165) [Young people charged through the courts were sent there for “specialist youth residential rehabilitation” in a wilderness setting.]

Suicides

• Many survivors died while they were in care or by suicide following care. For others, the impacts of abuse are ongoing and compounding, making everyday activities and choices challenging. (Point 33, page 36)

• A 1979 letter from the psychiatric medical officer at Hawke’s Bay Psychiatric Unit to Porirua Hospital states: “I wish [Paul] better luck with his mutilation … since the only real relief I can see for him is in his death.” Paul took his own life nine months later. (Point 700, page 216)

Medical Experimentation

• Dr Olive Webb told the Inquiry she was aware of research being conducted at Māngere Hospital and the Templeton Centre near Ōtautahi Christchurch, where prescribed medications were being manipulated. She said that when the researcher was at a meeting with psychologists, he chuckled and said: “It’s great because the retards are one step higher than rats.” (Point 783, page 236)

RECOMMENDATIONS

Prohibition

• All human beings have intrinsic worth, inherent dignity and certain inalienable rights because they are human. Upholding the principle of human dignity has at least five aspects:

• banning all types of inhuman treatment, humiliation, or degradation of one person by another person
  • protecting bodily and mental integrity
  • ensuring the possibility of individual choice and the conditions for each person’s self-fulfillment, autonomy or self-realization
  • recognizing that protecting peoples’ self-determination, identity and culture may be needed to protect personal dignity, and
  • creating the conditions to ensure each person can have their essential needs met. (Point 276, page 148)

• Recommendation 72: The government should take steps to ban pain compliance techniques in any care setting for children, young people or adults in care. (page 215)

• Recommendation 74: The government should prioritize and accelerate work to minimize and eliminate solitary confinement in all care settings as soon as practicable, with an emphasis on person-centered and culturally appropriate approaches to reduce the use of solitary confinement safely. (page 217)

• Recommendation 119: The government should review Aotearoa New Zealand’s human rights framework to ensure it adequately addresses abuse and neglect in care, including:

1. introducing a stand-alone right to security of the person in the New Zealand Bill of Rights Act 1990

b. ensuring statutory protection in a Disability Rights Act of the rights of disabled people to be free from abuse and neglect in care and the relevant rights in the Convention on the Rights of Persons with Disabilities

c. providing statutory protection of the rights of Māori to be free from abuse and neglect in care and the relevant rights in the United Nations Declaration on the Rights of Indigenous Peoples

d. making any necessary amendment to the Human Rights Act 1993 to address abuse and neglect in care

e. the provision of effective implementation of the relevant rights, including positive duties (page 301)

Complaints Mechanisms & Oversight

• “Accountability for abuse in care has been the exception rather than the norm. There was a lack of clear and accessible complaints processes in many settings, and little accountability where standards of care were breached….” (Point 93, page 42)

• The Inquiry has recorded its concerns about survivors not having access to an effective remedy for abuse and neglect in care, including compensation (point 135, page 91)

• Effective complaints mechanisms need to be established that won’t be ignored. Record-keeping requirements are also critical for the effective administration of complaints processes and for providing oversight of decisions made. (Point 309, p. 129)

• Recommendation 65:  Establish a better and more accountable complaints system (pp. 198-199)

• Recommendation 66: Where a complaint has been substantiated, relevant professional bodies should take steps to ensure the person or people responsible are held accountable, including:

a. professional disciplinary action

b. reporting to the relevant professional registration body or bodies

c. reporting to the Care Safe Agency

d. reporting to NZ Police

e. reporting in accordance with any other applicable information sharing or mandatory reporting obligations. (page 201)

• Recommendation 69: The government should introduce legislation where necessary to create a coherent mandatory reporting regime which:
• applies to entities providing care directly or indirectly to children, young people and adults in care
• applies to all staff and care workers who work for the entities, outlined in (a) above, including foster parents, volunteers, chief executives, trustees, board members, etc. who receive disclosures of abuse and neglect during religious confession
• ensures obligations are clear, consistent, established in legislation and should include protections from liability for those making good faith notifications
• ensures access to timely advice on reporting obligations (page 206)

• Recommendation 67: All entities providing care directly or indirectly and relevant professional registration bodies should report all complaints, disclosures or incidents to the Care Safe Agency, whether substantiated or not substantiated following investigation. (page 203)

• Recommendation 86: The government should ensure that there are no unreasonable barriers preventing all responsible oversight bodies from investigating complaints, proactively monitoring the care system, and collaborating as appropriate to enable a whole of system view, including: a. reviewing and addressing any barriers or constraints in the entities’ enabling legislation, and b. ensuring the entities are adequately resourced. (page 236)

• Recommendation 87: The responsible oversight bodies should: a. investigate complaints about care workers; b. proactively monitor the way in which care providers and the Care Safe Agency investigate and respond to complaints; d. publish reports on their activities including on the outcomes of specific investigations or other monitoring functions; e. share information with the Care Safe Agency, including:

1. data, statistics and other information about the prevalence and nature and extent of abuse and neglect in care.
   1. insights about abuse and neglect in care including the effectiveness of different practices to prevent and respond to abuse and neglect in care.
   1. refer the results of their investigations and other monitoring functions to enforcement or regulatory bodies including NZ Police, the Charities Commission or the Care Safe Agency. (page 236)

Compensation

• Recommendation 11

b. survivors should be fairly and meaningfully compensated for all direct and indirect losses that flow from the abuse and neglect they experienced in care and that are covered by the new puretumu torowhānui system  [Built around apologies, ongoing support and appropriate compensation for harm done]and scheme c. the application process should be survivor-focused, trauma-informed and delivered in a culturally and linguistically appropriate manner. (page 93)

• Recommendation 30 The government should amend section 11 of the Victims Rights Act 2002 to ensure that victims of abuse and neglect in care must be advised of the ability to seek redress in the civil courts and through the puretumu torowhānui system and scheme, and their right to apply for legal aid for civil proceedings. (p. 122)

• Recommendation 31:  The Ministry of Justice should establish a list of specialist lawyers available to provide legal advice to victims about seeking puretumu torowhānui (holistic redress). (page 122)

Judicial and Human Rights-Based Justice

• NZ Police must work proactively to ensure that survivors, their whānau [Māori extended family] and support networks know about investigations into possible torture or cruel, inhuman or degrading treatment or punishment. This should include communication and advertising that is culturally appropriate and tailored to survivor needs to take account of barriers that may prevent people from contacting NZ Police. (Point 125, page 87)

• All international obligations adopted by Aotearoa New Zealand should be considered during criminal investigations, and when decisions are made about whether to charge a person, and other prosecution decisions. These obligations should be considered at every step of the prosecution process, including when considering the victims of crime. All prosecution guidelines issued by the Solicitor-General should be amended to ensure they are consistent with Aotearoa New Zealand’s human rights obligations including the United Nations Convention on the Rights of Persons with Disabilities, the United Nations Convention on the Rights of the Child, and the United Nations Convention on the Rights of Indigenous Peoples. (Point 195, page 112)

• Recommendation 6: Where there are reasonable grounds to believe that torture, or cruel, inhuman or degrading treatment or punishment have occurred in care directly or indirectly, and the relevant allegations have not been investigated by NZ Police or credible new information has arisen since the allegations were investigated, NZ Police should:

a. open or re-open independent and transparent criminal investigations into possible criminal offending

b. proactively and widely advertise the intent to investigate and ongoing investigations

c. provide appropriate assistance and support to survivors, their whānau and support networks who contact them in relation to the investigations (page 87)

• Recommendation 7: Where there are reasonable grounds to believe that torture, or cruel, inhuman or degrading treatment or punishment have occurred in care, indirect care providers should:

a. provide reasonable assistance to any NZ Police investigation

b. take all reasonable steps to ensure an impartial and independent investigation is carried out by an appropriate investigator

c. if there is credible evidence of breaches of the law (including breaches of human rights), ensure that appropriate redress is provided to the survivors, consistent with applicable domestic and / or international obligations

d. use best endeavors to have the liability of every relevant institution in relation to such acts determined. This may include:

1. Seeking opinions from King’s Counsel, which are then shared with relevant survivors, on the nature of the conduct and the liability of relevant institutions, including as applicable under the New Zealand Bill of Rights Act 1990. Consideration may also be given to seeking declaratory judgments from the courts. Survivors should be fully supported to take part in these initiatives, including with funding for legal and other expenses
   1. not pleading limitation defenses in cases brought by survivors, for as long as limitation defenses remain available. (p. 88)

• Recommendation 33: The Ministry of Justice, Te Kura Kaiwhakawā Institute of Judicial Studies, NZ Police, the Crown Law Office, the New Zealand Law Society and other relevant legal professional bodies should ensure that investigators, prosecutors, lawyers, and judges receive education and training from relevant subject matter experts on:

a. the Inquiry’s findings, including on the nature and extent of abuse and neglect in care, the pathway from care to custody, and the particular impacts on survivors of abuse and neglect experienced in care

b. trauma-informed investigative and prosecution processes

c. all forms of discrimination

d. engaging with neurodivergent people …

e. human rights concepts, including the obligations under the Convention on the Rights of Persons with Disabilities, the Convention on the Rights of the Child, the Convention on the Elimination of All Forms of Discrimination against Women, the Convention on the Elimination of All Forms of Racial Discrimination, and the United Nations Declaration on the Rights of Indigenous Peoples. (page 123)

• Recommendation 34: NZ Police should review the Police Manual and other relevant material to ensure instructions and guidelines reflect and refer to Aotearoa New Zealand’s international human rights obligations and other relevant international law obligations (including the Convention on the Rights of Persons with Disabilities, the Convention on the Rights of the Child, the Convention on the Elimination of All Forms of Discrimination against Women, the Convention on the Elimination of All Forms of Racial Discrimination, and the United Nations Declaration on the Rights of Indigenous Peoples) (page 124)

• Recommendation 35: NZ Police should establish a specialist unit dedicated to investigating and prosecuting those responsible for historical or current abuse and neglect in care. (page 125)

Deaths and Unmarked Graves

• The Inquiry has not only received evidence of people dying in care but also of people in care being buried in unmarked graves. (Point 93, page 45) In 2014, a local historian identified 172 unmarked graves at Waitati Cemetery, Otago. About 85% of these graves are from former institutions such as Cherry Farm (psychiatric hospital) and Seacliff. The historian noted that the last burial was in 1983. (Point 98, page 45)

• The inquiry found Evidence of unmarked graves for patients who died at some psychiatric hospitals across Aotearoa New Zealand, particularly at Porirua, Tokanui and Sunnyside Hospitals. (Point 77c, page 54)

• Recommendation 19: The government should appoint and fund an independent advisory group to investigate potential unmarked graves and urupā at the sites of former psychiatric and psychopaedic hospitals, social welfare institutions or other relevant sites. (p. 89)

Change Streets Named In Honor of Identified Perpetrators

• Recommendation 5: All entities that provide care, or have provided care, directly or indirectly should:

a. review the appropriateness of any streets, public amenities, public honors or memorials named after, depicting, recognizing or celebrating a proven perpetrator of abuse and neglect in care and / or an institution where proven abuse and neglect took place

b. consider what steps may be taken to change the names and what else should be done to address the harm caused to survivors by the memorialization of proven perpetrators and institutions where abuse and neglect took place. (p. 85)

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[1] https://www.kiro7.com/news/world/report-says-200000/ODY2KOPAXBEIHIIYP3ZWYEESPY/

[2] “200,000 Children and Vulnerable Adults Abused in New Zealand, Report Finds,” The New York Times, 24 July 2024, https://www.nytimes.com/2024/07/24/world/asia/new-zealand-abuse-in-care-report.html

[3] https://www.1news.co.nz/2024/07/24/horrific-and-harrowing-parliament-responds-to-abuse-in-care-report/ l; https://www.nytimes.com/2024/07/24/world/asia/new-zealand-abuse-in-care-report.html

[4] https://www.cchrint.org/2024/02/23/cchr-and-electroshock-survivors-reject-apology-for-tortured-children/

[5] https://www.1news.co.nz/2024/07/24/horrific-and-harrowing-parliament-responds-to-abuse-in-care-report/ catchall

[6] Radio New Zealand: “Calls for action follow Abuse in Care inquiry’s final report” https://www.rnz.co.nz/news/national/523037/calls-for-action-follow-abuse-in-care-inquiry-s-final-report

[7] https://www.cchrint.org/2021/07/01/cchrs-work-acknowledged-nz-inquiry-lake-alice-psychiatric-child-torture/

[8] Whanaketia – Through pain and trauma, from darkness to light Whakairihia ki te tihi o Maungārongo, released 24 July 2024, https://www.abuseincare.org.nz/reports/whanaketia

[9] “Luxon speaks to survivors of abuse in care,” Timx`x`es.co.nz, 24 July 2024, https://www.times.co.nz/news/luxon-speaks-to-survivors-of-abuse-in-care/

[10] https://www.yahoo.com/news/zealand-apologise-enquiry-finds-200-040324903.html?fr=yhssrp_catchall