"The report serves as a critical reminder of the need to place the voices of people who receive care and support at the centre of services and uphold their fundamental rights to respect, dignity and safety.

"The report honours the experiences of those people who courageously told their stories in the hope that others do not experience abuse and neglect in care. Their stories will serve as an enduring reminder that we must all work towards the collective change required to prevent systemic abuse and neglect, " said Morag McDowell.

Ms McDowell says HDC continues to see a small but unacceptable number of cases where people have experienced abuse and neglect in care settings.

"It is clearly unacceptable for people to be subject to trauma and harm in the places where they are meant to be safe, and by the people who are there to care for them. I support many of the recommendations of this report and will work to uphold people’s rights with a view to improving systems and other safeguards to prevent continued recurrence of abuse and neglect."

She says a recent report by HDC into the themes in complaints about residential disability support services echoes some of the findings and recommendations of the Inquiry.

"HDC’s report highlighted the need for greater monitoring of the support delivered to disabled people and the critical role that robust safeguards and accessible and effective complaints mechanisms play in upholding people’s rights."

Ms McDowell acknowledges the findings of the Royal Commission that complaints mechanisms were not always effective in addressing incidences of abuse and neglect. She notes that disabled people|tāngata whaikaha and people experiencing mental health and addiction issues|tāngata whai ora continue to face multiple barriers to making a complaint, not least of which is their inability to withdraw from the care provided.

"I am pleased to see the Royal Commission making a number of recommendations about the implementation of accessible, culturally appropriate and effective complaints mechanisms. Many of the recommendations are consistent with the Code of Rights which gives people using health and disability services the right to complain, and requires providers to facilitate the fair, simple, speedy resolution of complaints.

"The Royal Commission also highlights the importance of independent advocates in mitigating the inherent power imbalance between people receiving care and providers. HDC’s contracted National Advocacy Service plays a vital role in supporting people to resolve their concerns with providers, assisting people to complain to HDC where necessary, and helping people to understand their rights under the Code.

"HDC and the Advocacy service have a key role to play in promoting and protecting the rights of disabled people|tāngata whaikaha and people experiencing mental health and addiction issues|tāngata whai ora, including by holding providers to account where necessary.

"HDC has made several important changes in recent years to allow us to better monitor and report on the experience of people in the care of health and disability services. We have strong processes to ensure public safety issues are urgently escalated and addressed, and we closely monitor our complaints data and take a collaborative approach to sharing this information with other agencies to improve the quality of care and support provided to people. I welcome any recommendations to increase our capacity to monitor the system and encourage collaboration."

Ms McDowell notes the report has been released during HDC’s public consultation on a review of the HDC Act and Code which has a focus on the Act and Code working better for disabled people |tāngata whaikaha and Māori.

"I acknowledge that our own complaints processes need to keep evolving towards becoming more culturally appropriate, accessible, timely, and responsive, and I will be looking at how we can incorporate the learnings from this Royal Commission into our review of the HDC Act and Code, as well as our complaints and organisational processes."

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