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Public acknowledgments and apologies for historical abuse and neglect in the care of the State (both direct and indirectly provided care) and faith‑based institutions should be made to survivors, their whānau and support networks by:

1. a. the most senior leaders of all faith‑based institutions and in particular, and without limitation:
   1. the Pope should make a public apology and acknowledgement for the abuse and neglect in the care of the Catholic Church in Aotearoa New Zealand
   2. the Archbishop of Canterbury should make a public apology and acknowledgement for the abuse and neglect in the care of the Anglican Church in Aotearoa New Zealand and Polynesia
   3. the President Elect should make a public apology and acknowledgement for the abuse and neglect in the care of the Methodist Church in Aotearoa New Zealand
      1. the Moderator of the Presbyterian Church of AotearoaNew Zealand should make a public apology and acknowledgement for the abuse and neglect in the care of the Presbyterian Church of New Zealand
   4. the Chief Executive Officer (or equivalent) of each individual Presbyterian Support  Organisation should make public apologies and acknowledgements for abuse and neglect in the care of their respective Presbyterian Support organisation
   5. the General of The Salvation Army should make a public apology and acknowledgement for the abuse and neglect in the careof The Salvation Army of New Zealand, Fiji, Tonga and Samoa Territory
      1. the Overseeing Shepherd should make a public apology andacknowledgement for the abuse and neglect in the care of Gloriavale Christian Community
   6. the Governing Body of Jehovah’s Witnesses should make a public apology and acknowledgement for the abuse and neglect in the care of Jehovah’s Witnesses in New Zealand.
   7. public sector leaders, including the Public Service Commissioner, Solicitor‑General, Commissioner of NZ Police and the Chief Executives of Oranga Tamariki, the Ministry of Social Development, the Ministry of Health, and the Ministry of Education
   8. 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, New Zealand Nurses Association, Teaching Council of Aotearoa New Zealand
   9. the leaders of all direct and indirect care providers, including Blind Low Vision NZ and IHC.
2. Each public apology should be:
   1. developed and agreed with a representative group of survivors
   2. be consistent with the puretumu torowhānui system and scheme and the Holistic Redress Recommendations from the Inquiry’s interim report, He Purapura Ora, he Māra Tipu: From Redress to Puretumu Torowhānui

The Solicitor‑General should: 

1. amend the suite of prosecution guidelines to include a requirement that those making decisions about whether to prosecute, and which charges to file, act consistently with New Zealand’s international human rights obligations and other relevant international law 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 Declaration on the Rights of Indigenous Peoples).
2. amend the suite of prosecution guidelines to include, in relation to the evidential test for prosecution, a requirement that those making assessments on the credibility and quality of a complainant’s evidence recognise the potential for their own bias, obtain relevant expert advice where necessary, and provide appropriate accommodations where necessary.
3. amend the suite of prosecution guidelines to include, as a public interest consideration for prosecution, that the offence was committed against a person in the care of the State or a faith‑based institution
4. amend the suite of prosecution guidelines to strengthen obligations to engage appropriately (that is, more than consult) with complainants (including the use of communication assistance) on prosecution decisions, including when considering whether to prosecute because of the likely detrimental effect on a witness’s physical or mental health.
5. amend the suite of prosecution guidelines to establish a review process for complainants who allege offences falling under Parts 7 or 8 of the Crimes Act 1961 where a decision has been made not to prosecute by NZ Police or a Crown Solicitor, which:
   1. is designed to ensure fairness and consistency in approach to charging decisions nationwide
   2. requires an evaluative review of the evidence and the decision not to prosecute. 
   3. establishes national panels of suitably trained and experienced prosecutors to conduct reviews of decisions not to prosecute made by NZ Police and Crown Solicitors.
   4. includes a requirement for the panel reviewing NZ Police decisions not to prosecute to seek legal advice from a Crown Solicitor where the decision is finely balanced and / or complex, or is an offence listed in the schedule to the Crown Prosecution Regulations 2013.
   5. has the power to refer a decision not to prosecute back to the decision maker for further consideration and / or investigation.
   6. ensures complainants are consulted in person with necessary accommodations.

The government should establish a new standalone Care Safe Agency, with an independent Board to oversee it. The Care Safe Agency should be tasked with functions that include:

1.  whole of system leadership on preventing and responding to abuse and neglect in care
2. promoting and championing the Care Safety Principles (Recommendation 39)
3. leading development and implementation of a National Care Safety Strategy and a supporting action plan to prevent and respond to abuse and neglect in care (Recommendation 40)
4. setting care safety rules and standards (legislative and non- legislative) (Recommendation 47)
5. monitoring and investigating compliance with the care safety rules and standards (Recommendation 47)
6. enforcing penalties and sanction for breaches of the care safety rules and standards (Recommendation 47)
7. developing best practice guidelines on care safety and preventing and responding to abuse and neglect in care
8. investigating and reporting on complaints received directly from users of supports and services
9. collating and keeping a centralised database of issues of concern, complaints, and the outcomes of investigations from all State and faith-based entities that provide care directly or indirectly to children, young people and adults in care, from professional registration bodies, and from independent oversight and monitoring entities (Recommendations 67–68)
10. accrediting all State and faith-based entities providing care directly or indirectly to children, young people, and adults in care (Recommendation 48)
11. registering staff and care workers who are not already covered by existing professional registration regimes (Recommendation 57)
12. promoting a continuous improvement and learning culture in the care system, including facilitating regular forums and communities of practice and evaluation
13. setting training and education standards and developing curriculums for staff and care workers
14. workforce development and developing career pathways for staff and care workers (Recommendation 61)
15. leading public awareness, education, and prevention initiatives (Recommendations 111–112 and 121–122)
16. undertaking research, data analysis and horizon-scanning, including building evidence on the risk, extent and impact of abuse and neglect in care
17. publishing data and statistics on complaints of abuse and neglect in care to promote transparency and measurability of outcomes
18. advising government on preventing and responding to abuse and neglect in care, including where systemic deficiencies are identified.

In defining the scope and functions of the independent Care Safe Agency, the government should consider the additional points made in Chapter 3 of Part 9.

All State and faith‑based entities providing care directly or indirectly should have safeguarding policies and procedures in place that:

1. are consistent with the Care Safety Principles (Recommendation 39). 
2. are consistent with the National Care Safety Strategy (Recommendation 40.
3. are compliant with care safety rules and standards (Recommendation 47).
4. re consistent with best practice guidelines issued by the Care Safe Agency.
5. are tailored to the risks of the particular organisation and care provided.
6. are clearly written.
7. are published in a readily accessible format.
8. give effect to te Tiriti o Waitangi.
9. are culturally and linguistically appropriate.
10. are responsive to the needs of children, young people and adults in care, including Māori, Pacific Peoples, Deaf, disabled people, people experiencing mental distress, and Takatāpui, Rainbow and MVPFAFF+ people.
11. are regularly reviewed, including periodic external reviews.
12. are audited for compliance, including periodic external audits.

All State and faith‑based entities providing care directly or indirectly to children, young people and adults in care and relevant professional registration bodies should ensure they have appropriate policies and procedures in place to respond in a proportionate way to complaints, disclosures or incidents of abuse and neglect, including:

1. the policies and procedures are guided by the Care Safety Principles (Recommendation 39) and any relevant rules, standards or guidelines issued by the Care Safe Agency (Recommendation 41).
2. the policies and procedures are clearly written, accessible to people in care, 
3. the policies, at a minimum, outline roles and responsibilities, how different types of complaints will be handled, including potential employment outcomes and reporting obligations.
4. the policies set out how actual or perceived conflicts of interest will be addressed if they arise.
5. there are clear protections in place for whistleblowers and those making good faith notifications.
6. it is as easy as possible for people to make disclosures or complaints
7. complaints processes are appropriate for Māori, Pacific People, Deaf, disabled people, people who experience mental distress and Takatāpui, Rainbow and MVPFAFF+ people including ensuring there is access to appropriate support.
8. complainants are supported and kept informed throughout the handling of their complaint, including with the assistance of their independent advocates (Recommendation 76) if applicable.
9. Complainants are kept safe throughout the handling of their complaint, including if they have complained about another person in care or a person who directly provides them care.
10. Complaints are responded to promptly and robustly, including: 
    1. as soon as a complaint is made, carrying out an initial risk assessment to identify the risks to the complainant and to other children, young people and adults in care.
    2. mitigating identified risks while the complaint is being investigated, proportionate to the seriousness of the allegation.
    3. continuing to investigate and report on complaints even if the subject of the complaint voluntarily leaves employment and / or cancels their professional registration.
    4. carrying out a robust investigation at a level proportionate to the seriousness of the complaint.
    5. applying a standard of proof consistent with civil law (“on the balance of probabilities”) when investigating complaints, but doing so flexibly, proportionate to the seriousness of the allegation.
    6. using external investigators where appropriate for the most serious allegations.
    7. meeting all privacy and employment law obligations.
    8. ensuring appropriate accountability, including through reporting to NZ Police and relevant professional registration bodies if the complaint is substantiated (Recommendation 66).
11. all complaints must be reported to the Care Safety Agency (Recommendation 41), regardless of the outcome of the investigation.
12. each complaint must be reviewed for lessons identified and possible improvements.
13. publicly report annually on how many complaints they are dealing with, whether they have been resolved, whether they have been substantiated, and how long the complaint took to be resolved.

The government should: 

1. provide sufficient investment to enable children, young people, and adults in care to have access to an independent advocate of their choosing to support them to understand and exercise their rights, specifically: 
   1. each child, young person and adult in care and protection, youth justice, disability and mental health settings should have access to an individual independent advocate.
   2. children and young people in State, State-integrated and private schools should have access to at least one independent advocate per school.
2. provide that independent advocates: 
   1. have appropriate communication skills (including for Deaf and disabled people in care).
   2. be independent from the care provider, and staff and care workers.
   3. be independent from their direct and immediate whānau of the person in care.
   4. proactively and regularly engage with the person in care, be available to respond in times of need, support the person in care when they need to raise issues with their carer, advocate for the right conditions, and / or generally provide peer support.
   5. have no power over the individual.
3. provide that advocates are subject to the same regulatory standards and safeguards, including vetting, registration and training as other staff and care workers.

Commissioners Erueti and Gibson consider the government should:

1. develop, plan for, and establish an independent entity, as soon as possible, responsible for: 
   1. commissioning care and protection, youth justice, community mental health, disability and preventative services and supports from self-identified local (or in some cases, national) community groups and organisations (including hapū, iwi, urban Māori authorities, NGOs, Pacific, disability, mental distress communities, faith-based entities, and other collectives) across Aotearoa New Zealand.
   2. monitoring and evaluation of the delivery of care and protection, youth justice, community mental health, disability and preventative services and supports by local community groups and organisations to ensure that they are meeting the needs of individuals and whānau in their communities.
   3. investing in local community groups and organisations to build their capacity and capability to design and deliver these supports and services to meet the needs of their communities.
   4. reporting to government, Parliament and the public on the delivery of care and protection, youth justice, community mental health, disability and preventative services and supports by local community groups and organisations to ensure that they are meeting the needs of individuals and whānau in their communities.
2. provide sufficient and sustainable investment to the Commissioning Agency to enable it to commission care and protection, youth justice, community mental health, disability and preventative supports and services that will meet the needs of individuals and whānau nationwide.
3. transfer responsibility and investment for commissioning the following services and supports to the Commissioning Agency: 
   1. care and protection supports and services, from Oranga Tamariki.
   2. youth justice supports and services, from Oranga Tamariki.
   3. community mental health supports and services, from the Ministry of Health / Health New Zealand Te Whatu Ora.
   4. disability supports and services, from Whaikaha preventative supports and services, from Te Puni Kōkiri / Whānau Ora commissioning entities.
   5. preventative supports and services, from Te Puni Kōkiri / Whānau Ora commissioning entities.