Main Report

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Foreword

Looking back at our history offers the valuable gift of perspective, allowing us to trace the threads of consequence back through time and find lessons for the future.

Yet the further we stand from past events, the more difficult it becomes to inhabit the reality we lived in then – to recall the uncertainty, the incomplete information and the weight of decisions made amid so many unknowns. What appears obvious in hindsight was often far from clear at the time. The luxury of looking back can obscure the courage it took to move forward, and the complexity of navigating uncharted territory with only partial maps.

The COVID-19 pandemic took the world into new territory, confronting us with a public health emergency unprecedented in recent memory. Even once vaccines were developed, governments were continually required to make extraordinarily difficult decisions, balancing the need to protect the most vulnerable against the broader social and economic costs of restrictions. Decisions had to be made at great speed, sometimes with conflicting expert advice, incomplete scientific understanding and data, and no set procedures to follow.

The stakes were immense. Each choice carried the weight and quality of lives in the balance. Yet policy-makers could not delay some hard choices – they had to act knowing the full consequences of their decisions would only emerge over time.

In Aotearoa New Zealand, those decisions involved very significant and far-reaching uses of government power that completely changed people's lives. They deserve thorough review. As testing arrangements, lockdowns and vaccine requirements were put in place, New Zealanders could no longer work as usual, go to school, meet friends and loved ones, attend public events or access the services they relied on. All of us were faced with many unknowns and many stresses, whether emotional, physical or financial.

Overall, New Zealand's initial response to the COVID-19 pandemic was successful. The elimination strategy achieved its goal of saving many lives. The Inquiry's Phase One report found that while our lockdown measures were strict, New Zealand spent less time in lockdown than many other countries and experienced relatively good social and economic outcomes, at least at first. There were, however, many lessons to be learned and these were outlined in the Phase One report released in November 2024.

This is the report of Phase Two of the Inquiry. It covers the period from February 2021 to October 2022. At this time, New Zealand faced a different challenge than that presented in early 2020. It was one thing to implement and maintain a short-term elimination strategy to keep out or stamp out a disease. That was difficult enough. But when far more transmissible versions of the disease started making their way into the community, the difficulties compounded, especially as people become increasingly fatigued from life under pandemic restrictions.

The years 2021 and 2022 were a fraught transition period, with the country moving towards what everyone hoped would be a return to more normal life. The elimination strategy was no longer feasible, and so instead the Government turned to a strategy of suppression and minimisation. This approach sought to minimise the harms from COVID-19 while also learning to live with it in our communities.

The pandemic, and the response to it, has left scars. During the period examined in this phase, people continued to die and others suffered long-term health impacts. Some lost all faith in government and other institutions, and remain disengaged, sceptical or even hostile towards them today. We heard from many people who were angry about the restrictions that remained in force during this time, despite changing circumstances. We heard from others who considered some public health measures weren't adequate or safe.

The role of the Royal Commission of Inquiry into COVID-19 Lessons Learned has been to assess the decisions the Government made to manage the pandemic and to identify what can be learned. In Phase Two of the Inquiry, we have built on the work of Phase One, focusing particularly on the turbulent period described above and the key decisions the Government made about vaccine safety and approvals, vaccine mandates, testing and tracing arrangements, and lockdowns. Throughout, we have assessed whether the Government considered the impact these decisions might have on society, health, education and the economy, compared with the public health benefits, and whether they led to any unforeseen consequences.We have been able to examine some aspects of the response in more depth than was possible in Phase One, and also to consider some new areas – including some where we have had the benefit of new analysis and data that was not available to Phase One.

Overall, this report concludes that Aotearoa New Zealand did well in responding to the COVID-19 pandemic. On the whole, the decisions taken and methods used during the COVID-19 response were considered and appropriate. We have also identified where they were lacking. New Zealand's response strategy and settings weren't always sufficiently responsive to changing circumstances; for example, they weren't adapted early enough to deal with later variants of the virus. At a time when speed was often critical, some decisions had to be made without enough information and data, or without sufficient consideration of all the impacts that might arise, or without important checks and monitoring.

As this report identifies, there is scope to do better in another pandemic – although we acknowledge that some adverse impacts are inevitable in any such event, and difficult choices and trade-offs will always have to be made. Based on our assessment of the key COVID-19 decisions, we have identified four broad lessons and made recommendations for how Aotearoa New Zealand can prepare for, respond to and recover from future pandemics. These are intended to inform sound decision-making.

As in Phase One, one message emerges strongly: good decisions matter. They matter for the health, wellbeing, safety and prosperity of individual New Zealanders and for our society, and they especially matter in difficult times. We urge the Government to consider the lessons presented here and implement the recommendations – along with those made in Phase One – as soon as possible.

This report is based on evidence gathered over the past 15 months. We not only received thousands of pages of documents (including public submissions) but also met with a wide range of people and organisations – in interviews, community engagements around the country and public hearings. We felt it was important to hear, first-hand, about the experiences of living through the pandemic and the response. We heard from those who lost their jobs or whose relationships suffered because of vaccine mandates. We heard the fears of those whose health issues made them extremely vulnerable to COVID-19. We heard from those who had difficult experiences being vaccinated. We heard from frontline workers who were abused for doing their jobs. And we heard from those who made the difficult decisions that set the course of the response, day after day, under sometimes relentless pressure.

Still to this day, people feel deeply about the Government's response to the pandemic – whether strongly in favour, strongly against or somewhere in between. We have listened closely to this range of experiences and perspectives. What people shared with us – often heartfelt and personal – forms part of the record of the pandemic created by this Inquiry and should not be forgotten.

We hope that this well-informed record will remind everyone that, while we all experienced COVID-19, we experienced it differently. More than five years since the pandemic began, it is time to revisit some of the most frustrating aspects of it, listen to those whose experiences differed from our own and perhaps moderate our views as a result. We trust that the work undertaken in both phases of this Inquiry – combined with the passage of time – will allow us all to move forward together with more understanding, empathy and respect for different perspectives.

Aotearoa New Zealand will doubtless face another pandemic in future. It is vital that, collectively, we learn from what we have been through. Together we must ensure the lessons learned serve us well in preparing for whatever may come next.

Ngā manaakitanga,

Grant Illingworth KC, Chair

Grant Illingworth KC
Chair

Anthony Hill, Commissioner

Anthony Hill
Commissioner

Judy Kavanagh
Commissioner

Kupu Whakataki |
Foreword

Ko te titiro whakamuri ki tō tātou hītori he koha nui. Nā te tirohanga hōhonu ka āhei tātou ki te whai i ngā whenu o ngā pānga puta noa i te wā, kia kitea ai he akoranga mō anamata.

Heoi anō, i te mea ka tino tawhiti haere ngā kaupapa o mua, ka uaua ake te hoki ki te ao i noho ai tātou i taua wā – te maumahara ki te rangirua, ki te mōhiohio hukihuki, me te taumaha o ngā whakatau i whakatauhia i waenga i te nui o ngā mea kāore i mārama. Ko ngā mea e mārama ana ināianei i muri i te tirohanga whakamuri, he mea kāore i tino mārama i taua wā. He wā ka huna te painga o te tirohanga whakamuri i te māia i hiahiatia kia anga whakamua, me te uaua o te whakatere i ngā āhuatanga kāore anō kia rangahaua, me ngā mahere hukihuki noa.

I kawea te ao whānui e te mate urutā COVID 19 ki tētahi ao hou, ki tētahi āhuatanga hauora tūmatanui kāore i kitea i roto i ngā tau tata nei. Ahakoa i whakawhanaketia ngā rongoā ārai mate, he herenga tonu mā ngā Kāwanatanga kia whakatau i ngā take tino uaua. Me tere rawa ngā whakatau; i ētahi wā i taupatupatu ngā tohutohu a ngā mātanga, he hukihuki ngā mōhio pūtaiao me ngā raraunga, ā, kāore anō kia whakaritea he tikanga hei whai.

He nui rawa ngā tūraru. I ia kōwhiringa, i kawea te taumaha mō te oranga me te kounga o te oranga tangata. Heoi anō, kāore i āhei ngā kaiwhakatau kaupapa here te whakaroa i ngā kōwhiringa uaua – me mahi tonu rātou, ahakoa te mōhio ka puta mai ngā pānga katoa o ā rātou whakatau ā muri ake.

I Aotearoa, i pā aua whakatau ki ngā āhuatanga whānui, hira hoki o te mana kāwanatanga, ā, i tino whakarerekētia ngā āhuatanga o te oranga o te iwi whānui. E tika ana kia āta arotakengia. I te whakatinanatanga o ngā whakamātautau, ngā rāhui, me ngā herenga werohanga, he maha ngā tāngata o Aotearoa kāore i āhei ki te mahi i ā rātou mahi tikanga, ki te haere ki te kura, ki te tūtaki ki ngā hoa me ngā whanaunga, ki te tae atu ki ngā hui tūmatanui, me te whai wāhi hoki ki ngā ratonga i whakawhirinaki ai rātou. I ūhia tātou katoa e te kore mōhio me te manukanuka – ā-roto, ā tinana, ā pūtea hoki.

I te nuinga, i angitū te whakautu tuatahi a Aotearoa ki te urutā COVID 19. I tutuki i te rautaki whakakore te whāinga kia ora ai te tokomaha. I kitea e te pūrongo Wāhanga Tuatahi, ahakoa he kaha ngā here rāhui, he poto ake te wā i noho rāhui ai a Aotearoa i ērā atu whenua maha, ā, i pai ake hoki ngā putanga pāpori me ngā putanga ōhanga i te tīmatanga. Heoi anō, he maha tonu ngā akoranga i puta, ā, i tohua ēnei ki te pūrongo Wāhanga Tuatahi i tukuna i Noema 2024.

Ko tēnei te pūrongo o te Wāhanga Tuarua o te Uiui. E kapi ana i te wā mai i Pēpuere 2021 ki Oketopa 2022. I taua wā, he rerekē te wero i mua i a Aotearoa i tō te tau 2020. He mea kotahi te whakatinana i tētahi rautaki aukati mō te wā poto hei aukati, hei tinei rānei i te mate – he uaua kē tērā. Engari i te putanga mai o ngā momo huaketo horapa tere ake, ka kaha ake ngā uauatanga, ā, ka ngenge hoki te iwi i raro i ngā here mate urutā.

Ko ngā tau 2021 me 2022 he wā whakawhitinga taumaha, e anga ana ki te tūmanako kia hoki ki te ao āhua noa. Kāore e taea te rautaki aukati te whai tonu, nō reira ka tahuri te Kāwanatanga ki te rautaki whakaiti me te pēhi. Ko te whāinga kia whakaiti i ngā kino o COVID 19, i te wā anō e ako ana te iwi ki te noho tahi me te mate i roto i te hapori.

He mamae i mahue mai i te mate urutā me te urupare i taua wā. I mate tonu ētahi, ā, i pā kino te hauora o ētahi mō te wā roa. I memeha te whakapono o ētahi ki te Kāwanatanga me ētahi atu whakahaere, ā, tae noa mai ki tēnei rā, ka noho wehe, rangirua, ā, ka tino riri hoki ētahi. I rangona e mātou te riri o ētahi mō ngā here i mau tonu, ahakoa ngā huringa āhuatanga. I rangona hoki e mātou te hunga i whakaaro he ngoikore, he kore haumaru ētahi tikanga hauora tūmatanui.

Ko te mahi a te Komihana a te Karauna mō ngā Akoranga o COVID 19 he aromatawai i ngā whakatau a te Kāwanatanga, me te tautuhi i ngā akoranga. I te Wāhanga Tuarua, i whakawhānuihia te mahi o te Wāhanga Tuatahi, me te aro ki ngā wā pōkaikaha i whakamāramatia i runga ake nei, me ngā whakatau matua a te Kāwanatanga mō te haumaru rongoā ārai mate, ngā here ārai mate, ngā whakamātautau me te whaiwhai, me ngā rāhui. I aromatawaitia mēnā i whai whakaaro te Kāwanatanga ki ngā pānga ki te hapori, te hauora, te mātauranga me te ōhanga, me te whakataurite ki ngā painga hauora tūmatanui, me te tirotiro hoki i ngā pānga kāore i whakaarotia. I āhei hoki mātou ki te tiro hōhonu ake ki ētahi wāhanga o te urupare i tua atu i āhei ai i te Wāhanga Tuatahi, ā, ki te whai whakaaro hoki ki ētahi wāhanga hou – tae atu ki ngā mea i puta mai i ngā tātaritanga me ngā raraunga hou kāore i whai wāhi i te Wāhanga Tuatahi.

I te mutunga, e whakatau ana te pūrongo he pai te urupare a Aotearoa ki te mate urutā. I te nuinga, he tika, he whaitake ngā whakatau me ngā tikanga. Heoi anō, i kitea hoki ngā wāhi ngoikore. Kāore i ngā wā katoa i tino urupare ngā rautaki me ngā whakaritenga ki ngā āhuatanga hurihuri; hei tauira, kāore i whakarerekētia wawe hei whakatika i ngā momo hou o te huaketo. I ētahi wā i tino hira te tere o te whakatau, ā, i tika kia whakatau kaupapa me te kore mōhio, raraunga rānei, me te kore whakaaro whānui ki ngā pānga ka puta, me te kore hoki o ngā arowhai me te aroturuki nui.

E ai ki tā tēnei pūrongo, he wāhi tonu hei whakapai ake mō tētahi atu urutā – ahakoa e mōhio ana mātou arā ētahi pānga kino ka kore e taea te karo i ngā āhuatanga pēnei, ā, ka noho tonu ngā kōwhiringa uaua me ngā tauutuutu hei whakatau. I runga anō i tā mātou aromatawai i ngā whakatau matua mō COVID 19, kua tautuhia e mātou e whā ngā akoranga whānui me ngā tūtohutanga hei whakarite, hei whakautu, hei whakaora anō i a Aotearoa i ngā urutā ā mua. Ko te whāinga, he tautoko i te whakatau tika.

Pērā i te Wāhanga Tuatahi, kotahi te karere i tino kitea: he mea nui te whakatau tika. He mea nui mō te hauora, te oranga, te haumaru me te tōnuitanga o ia tangata o Aotearoa me tō tātou hapori whānui, ā, he mea nui rawa atu i ngā wā uaua. E akiaki ana mātou i te Kāwanatanga kia āta whai whakaaro ki ngā akoranga kua whakaaturia ki konei, ā, kia whakatinana hoki i ngā tūtohutanga – me ngā mea o te Wāhanga Tuatahi – i te wā tonu.

E hāngai ana tēnei pūrongo ki ngā taunakitanga i kohia i roto i ngā marama tekau mā rima kua pahure. Ehara i te mea i whiwhi noa mātou i ngā mano whārangi o ngā tuhinga (tae atu ki ngā tāpaetanga tūmatanui), engari i tūtaki hoki mātou ki te whānuitanga o ngā tāngata me ngā rōpū – i roto i ngā uiuinga, ngā hui ā hapori puta noa i te motu, me ngā whakawā tūmatanui. I rangona ā kanohi tonu e mātou ngā wheako o te hunga i pāngia e te urutā me te urupare. I rangona ngā kōrero a te hunga i whakamutua ā rātou mahi, i pā kino rānei ā rātou whanaungatanga nā ngā here kano ārai mate. I rangona hoki ngā mataku o te hunga i tino mōrea nā ō rātou mate hauora ki te COVID 19. I rangona ngā kōrero a te hunga i uaua ā rātou wheako i te wā e werohia ana rātou. I rangona ngā kōrero a ngā kaimahi i te mura o te ahi, i tūkinohia e ētahi mō te mahi noa i ā rātou mahi. Ā, i rangona hoki ngā kōrero a te hunga nā rātou i whakatau ngā whakatau uaua, i whakatakoto i te ara o te whakautu, ia rā, ia rā, i raro i te pēhitanga mutunga kore.

Ā tae noa mai ki tēnei rā, he kaha tonu ngā kare ā roto o te iwi mō te urupare a te Kāwanatanga – ahakoa tautoko kaha, whakahē kaha, kei waenganui rānei. Kua āta whakarongo mātou ki ēnei momo wheako me ngā tirohanga huhua. Ko ngā kōrero i tukuna mai ki a mātou – he ngākau nui, he whaiaro hoki i te nuinga o te wā – ka noho hei wāhanga o te pūrongo mō te mate urutā i waihangatia e tēnei Uiui, ā, kei wareware i a tātou.

E tūmanako ana mātou mā tēnei pūrongo whai mōhio e whakamaumahara atu ki te katoa, ahakoa i pā te COVID 19 ki a tātou katoa, i rerekē tonu ngā wheako o tēnā, o tēnā. Neke atu i te rima tau mai i te tīmatanga o te mate urutā, kua tae ki te wā kia hoki anō ki ētahi o ngā wāhanga tino whakahōhā o taua wā, kia whakarongo hoki ki te hunga i rerekē atu ō rātou wheako i ō tātou, ā, tērā pea ka āta whakangāwari ake i ō tātou ake whakaaro. E whakapono ana mātou ko ngā mahi i mahia i ngā wāhanga e rua o tēnei Uiui – me te paheketanga o te wā – e āhei ai tātou katoa ki te anga whakamua tahi me te nui ake o te māramatanga, te aroha, me te whakaute ki ngā tirohanga rerekē.

Kāore e kore, ka pā mai anō he mate urutā ki Aotearoa ā tōna wā. He mea nui kia ako ngātahi tātou i ngā akoranga o ngā wā kua pahure, kia whai hua ai aua akoranga hei whakarite i a tātou mō ngā wero ka puta ā muri ake nei.