Those affected by the Christchurch mosque attacks have felt let down at every hurdle since March 15 last year, the Royal Commission of Inquiry has found.
Death certificates with spelling errors, family members having to work as translators for police interviews and widows being advised to put their children in care to apply for jobs are just some of the problems highlighted in the commission's report.
If the attack wasn't enough, they feel they've been failed by government agencies who were meant to help them.
Many told the commission the direct aftermath caused more grief and trauma as they were not told where their loved ones were.
Some resorted to watching the terrorist's video of the attack to try and figure out if their loved ones were alive or dead.
"An acquaintance of my parents said that she had seen [my brother] in operating theatre," a relative told the commission. "Mum and dad rushed to the hospital with this news and after waiting outside Al-Noor Mosque for four hours, they then proceeded to wait at Christchurch Hospital for another six hours.
"After this, they found out that the person my parents were waiting for, patient number 13, was not at all [my brother]. They were finally told my brother was unaccounted for."
The commission's report said affected whānau, survivors and witnesses felt the victim identification process and the process for identifying people being treated in hospital caused them additional and unnecessary grief.
The report said in one case a person read of their loved one's death in the newspaper before being told by police.
Many victims raised questions about the police's response on the day.
They told the commission the fact medical staff were not allowed inside the mosques straight away due to police cordons led to more deaths.
Since March 15, victims and families have struggled to get help, telling the commission they had to recount their experience of the attack over and over to different agencies.
"Going on a year post the attacks, families are still waiting for adequate wrap-around services that are culturally and linguistically responsive and which fully addresses their complex needs," a family representative told the commission.
Families went to meetings with public sector agencies which sometimes didn't have interpreters present.
"Affected whānau, survivors and witnesses needed to rely on whānau members to interpret police questions, we were told this exacerbated trauma," the report said.
It said those who dealt with government agencies including ACC, the Ministry for Social Development and Victim Support found overlaps in support and services and a lack of coordination between agencies.
"Where there should have been active listening, there is a deluge of information, where there should be advocacy there are endless meetings," a victim told the commission.
Some witnesses told the commission they were not eligible for financial support from the Accident Compensation Corporation as they had not suffered any physical injuries.
They felt their mental wellbeing continued to be affected by stress, depression, anxiety and difficulty sleeping.
They considered they were the forgotten victims of the attack.
Those affected by the attack also told the commission they have been re-traumatised by their interactions with public sector agencies since the attack.
A particular cause of this has been a lack of cultural competency and training within these agencies when dealing with trauma.
One victims and families representative told the commission that many witnesses to the attack were not provided support until third party advocates became involved, and some were not identified as victims, let alone witnesses until months later.
"Witnesses to the attack have suffered severe mental trauma, which some describe as a feeling of physically debilitating pain."
The commission made multiple recommendations around the support provided to those affected by the attacks.
The commission recommended the government directs the Ministry of Social Development to work with other agencies including ACC and the Ministry for Justice to facilitate coordinated access to on-going recovery support.
This includes assigning each whānau, survivor or witness a single point of contact who will navigate support for them.
RNZ
