It is hard to believe that torture, extreme violence and sexual abuse could have happened in the Hutt Valley. And to find that victims' families were not told by the school that their children had been subjected to this behaviour is every parent's nightmare.
The school did not refer the matters to the police or Child, Youth and Family (CYF), the perpetrators were not adequately punished and the school took it upon itself to interpret medical information in favour of the bullies. The Education Review Office failed to properly assess the safety of the school and CYF failed to manage a conflict of interest of its staff member also on the school's board of trustees.
This report has brought closure for the victims and their families by providing a comprehensive picture of what really happened. The ombudsmen also have the flexibility to look beyond the individual complaints to underlying systemic issues and to recommend policy changes which will have an impact on the whole sector.
They did all of these in the bullying report, recommending amending school national administration guidelines to make anti-bullying programmes mandatory in all schools, recommending that the Ministry of Education provide specific guidance to schools on what level of punishment is appropriate for various offences and actions and to improve disciplinary procedures by requiring principals and school boards to consider victims' views when making decisions on discipline in bullying or violence cases.
The measures are important because they address culture and culture change, something which a decision by a court cannot address.
New Zealand's first Ombudsman, Sir Guy Powles, said: "The Ombudsman is Parliament's man, put there for the protection of the individual and, if you protect the individual, you protect society."
The type of "administrative review/audit" that lies at the heart of a major Ombudsman investigation like the bullying report focuses on the impact on individual citizens and whether they have been treated by the state in a fair, just and transparent way.
The report is an in-depth, independent and impartial investigation of why individuals weren't protected in the way they should have been, leading to recommendations as to how we protect individuals and society in the future while ensuring transparent accountability.
Next year will be the 50th anniversary since the institution of the ombudsman was established in New Zealand. They guard the guardians.
They are more often my first port of call in problem solving for those with problems with government than any other complaint body. The ombudsmen are also the watchdogs under the Official Information Act, ensuring citizens and business can access government information to which they are entitled.
* Mai Chen is a partner with Chen Palmer and author of the forthcoming 'Public Law Toolbox.'