The report was clear efforts were made at an operational level to address problems with the fluoridation facilities, but a lack of oversight and prioritisation made for slow progress.

The insufficient visibility at governance and management levels to ensure effective fluoridation created a “corporate invisibility”.

“Over time, this has led to a lack of appreciation internally of the importance that stakeholders and the public place on effectively fluoridated water.”

Interviewees described a “reactive culture and learned helplessness” through which they gradually accepted investments to resolve systemic issues would not be granted.

This was compounded by the fact fluoridation facilities were not considered critical assets.

There were also historical challenges to providing fluoride safely.

These included shortages, resulting in bad quality powder being used and packaging breaking down and getting caught in the dosing system.

In a statement, Wellington Water board chairwoman Lynda Carroll said they apologised for the failings.

She said the findings gave them a clear direction on improvements they could make, many of which were put in place while the inquiry was being conducted.

“Our focus was on putting the situation right as soon as possible,” she said.

“When the board commissioned this independent inquiry, we were determined that the
inquiry would not slow the work to restore fluoride back in the drinking water at Te Marua
and Gear Island.”

Chief executive Colin Crampton said they were committed to ensuring the mistakes did not happen again.

“We have a September target date for getting fluoride back into the drinking water at the two plants. Greater Wellington Regional Council has approved funding to construct purpose-built standalone fluoride facilities for both plants. We have improved our fluoridation reporting to councils, on our website, in our Statement of Intent and as a formal performance measure,” he said.

The report’s recommendations:

• Maintain a relentless focus on effective fluoridation in both the short and long term.
• Make sure the board has the right collective experience and knowledge to govern effectively.
• Provide greater clarity of roles, responsibilities, and processes for managing fluoridation issues within Wellington Water.
• Improve the standard of asset management.
• Review the capacity for internal auditing.