A scathing review has found fluoridating water was "not a priority" for Wellington Water, and there were no plans to reinstate fluoride into the two cut-off water stations.
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After revelations earlier this year that two of Wellington's water treatment plants had ceased fluoridation for months, an internal review was launched and its findings released this afternoon.
Wellington Water has been told to take a "relentless" shift in focus to get fluoride back into Wellington's water systems, and fix its communication and leadership problems.
The report, conducted by Martin Jenkins, found there was a lack of urgency from Wellington Water to both get the fluoridation problem fixed and communicate the issue to its own senior leadership team, the board, councils, and the public.
Water in Wellington has been inconsistently fluoridated for the last six years.
The report found all water treatment plants fluoride concentrations were "frequently below the optimal level for oral health".
In March this year Wellington Water first revealed it had switched off its fluoride dosing at the plants since February.
Later that week board chair Lynda Carroll doubled down and told the public that information was wrong - sparking a review.
The inquiry report revealed the mistake was the result of "incomplete information" being provided to senior leadership in December 2021, mistaken
assumptions, and "inadequate quality assurance of communications".
Senior leadership and the board had not been told about the true dates of fluoridation being switched off until March this year.
It therefore took eight months from the first water treatment plant turning off its fluoride until Wellington Water had formed a team to do something about it.
However, the inquiry has concluded that there was no deliberate attempt to hide the length of time that fluoride had been turned off.
Bad communication and 'a lack of ownership'
There were no plans to turn the fluoride dosing back on at either plant when the operational teams flipped the switch last year.
The operational team, which turned the fluoride off, did not want turn it back on until it was safe - but it was not clear who in Wellington Water would take the lead on fixing the problem.
The report found "a lot of people know something needed to be done", but it was not prioritised effectively and there was a lack of urgency to get fluoride back on.
"A lot of people were copied into e-mails on the issue - from senior management levels to operational levels - without any clear requests or commissioning of work," the report said.
Internal e-mails show that it was suggested in October 2021 that the Wellington councils be informed of the fluoride issues. However, the report shows "there was a reluctance to do this until there was a firm plan in place for turning fluoridation back on".
Wellington Water's senior leadership team were told in December last year, immediately before the Christmas period, that there was "low and inconsistent" fluoride dosing - but not that both water plants were already not being fluoridated.
It was not until February this year, eight months after the first plant stopped fluoridation, that a project team was formed at Wellington Water to improve the issue.
Senior leadership met on 21 February and were briefed on the issue of fluoride - but no one in the team was aware that the dosing had stopped.
Wellington Water board may not be fit for purpose
The report says the Wellington Water board had a gap in its knowledge and experience of water services, and this limited its ability to know what questions it should have asked about fluoride.
It said there have been issues raised that the current number of members on the board may not be sufficient to provide "scrutiny and assurance required both for the issues that have emerged through this inquiry".
In particular, it suggests the board may not be large enough to operate.
'Relentless focus' on fluoridation must be maintained - report
The report says there needs to be a relentless focus not only on implementing the short-term solutions that will allow fluoridation to resume as quickly as possible, but also on long term solutions.
A "comprehensive communication plan" to keep the public informed on its action tracking is advised.
The Wellington Water board needs to have the right knowledge and experience to govern effectively, the report said.
It recommends the Wellington Water committee assesses the board to see if they fit the criteria.
A new assurance framework is needed, as well as detailed operational guidelines to ensure its staff know how to respond to and manage fluoride issues.
Wellington Water also needs to improve its assets - like the quality of its ageing treatments plants or its quality of fluoride powder.
Wellington Water committed to recommendations
Wellington Water's board and management have committed to implement the findings.
"The inquiry findings clearly identify where and how we failed, and we again apologise for those failings," Lynda Carroll, chair of Wellington Water's Board said.
"The findings and recommendations provide us with a clear direction on improvements we can make to ensure we deliver the level of performance that our customers and stakeholders expect and deserve. Many of these actions were put in place in parallel to the inquiry. Our focus was on putting the situation right as soon as possible," Carroll said.
Fluoride is set to be switched back on in September.
"We've also developed a detailed implementation plan to address the inquiry's five recommendations. Our work will focus on building on communications, risk identification and increased transparency to continue to give our board, stakeholders and the public assurance that we're doing our job properly," she said.
At a media conference today, Carroll said the company accepted accountability for not having fluoridated water.
When asked if Wellington Water would accept responsibility if it was found that oral health in the region has declined as a result, Carroll said "we certainly accept accountability for that".
Wellington Water says it can adopt the inquiry's recommendations by October this year.
Wellington Water chief executive Colin Crampton said the company was well on track to get fluoride back into the two water treatment plants by September.
He told media this afternoon the company had engaged with the Ministry of Health about what the entity had done and what it was going to do regarding fluoride.
All water treatments plants would get more testing more frequently and staff had been informed on how to raise issues effectively, he said.
The Wainuiomata and Waterloo plants would also be included in public fluoridation measuring on the website.
"The company has two tasks: to deliver safe drinking water for the residents of Wellington, which we do well," he said.
"The other is to fluoridate that water."
Fluoridation was now a priority set within all public accountability documents, and staff at Wellington Water had now made the link between fluoridation and oral health, Crampton said.
Wellington Water has now adopted the national fluoridation code of practice.
Higher quality fluoride powder was also being sourced, which the report found was an issue.
Te Mārua plant was suffering from poor-quality fluoride powder blocking the system and overdosing, while the Gear Island plant facility was old and breaking with age.
The system would have to be cleaned out and flushed before it could be turned on again - and the report notes it "was not unusual for operators to be called out in the middle of the night".