A support service failed to keep an intellectually disabled man safe from sexually inappropriate behaviour, according to the Health and Disability Commissioner.
A report released on Monday by Deputy Health and Disability Commissioner Rose Wall claimed IDEA Services and two of its staff members took little or no action - despite being aware of several events involving aggressive or sexual behaviour towards the man, known as Mr C.
Both men were attending a vocational service run by IDEA Services, which supports adults with intellectual disabilities, when the incidents occurred.
The report focused on two events in 2017 when the man touched Mr C's penis while in the bathroom. He was also found with his pants down, standing over Mr C while he was sitting on the toilet.
Wall criticised IDEA Services over its "widespread failure to escalate serious incidents".
She said the failures were systemic and involved staff from all levels, including management.
"IDEA Services failed to ensure that it had a positive organisational culture that treated Mr C's safety as paramount, and that all staff took a zero-tolerance approach to abuse," Wall said.
Wall recommended IDEA Services implement an electronic reporting system, audit its incident reporting and refresh staff training on the prevention and management of abuse.
The recommendations included "seeking independent advice on what further improvements could be made to its processes for team meetings, incident reporting and recording of family requests or concerns, and to foster an organisational culture focused on continuous improvement and zero-tolerance to abuse".
IDEA Services and the two staff members involved were also asked to apologise to Mr C's mother.
Wall asked the Ministry of Health and the Ministry of Social Development to update her on the steps they have taken to ensure a zero-tolerance approach to abuse within the disability support services they fund.
The case has been referred to the director of proceedings to decide whether any legal proceedings should be taken against IDEA Services in the Human Rights Review Tribunal.