Te taenga atu ki Lake Alice - Arriving at Lake Alice

192.    The experience of arriving at the unit was traumatic for most survivors. Some spoke about the distress experienced watching others arrive. For example, Ms LL told us, “I have a vivid memory of a young boy of five to six years old standing on the steps of Lake Alice holding a teddy bear and screaming for his mum and dad. He had been dropped off in a car and left alone there. He was pākehā. That cut me to the core”.^[433]

193.    Survivors often described their impressions of the buildings at Lake Alice as intimidating and prison-like. One survivor described not being told where she was going, being driven down a long road, seeing a building with high ceilings and big windows, and getting the feeling in her gut to run.^[434] Mr Jane also told us “the building was like a prison – all fenced up. Everyone was locked up, and you couldn’t get out. It was like going into maximum security”.^[435]

194.    Some Lake Alice survivors said their initial impressions of Dr Leeks were favourable. They used the terms ‘nice’,^[436] ‘kind’^[437] and ‘placid’^[438] to describe how they first saw him. However, these impressions often changed, as Mr Hendricks explained. “He was placid to talk to, but you couldn’t go against him, he was the boss. The less you had to do with him, the better. It wasn’t good when Leeks was around”.^[439] Ultimately, most survivors we spoke to remembered Dr Leeks as a frightening man they tried to avoid.

195.    Many survivors told us that arriving at the unit and meeting Dr Leeks was disorienting and processes weren’t explained to them. For example, Mr Richards told us:

“What I recall about my arrival was that Mum and I went into Dr Leeks’ office for about five minutes. He spoke to my mother, not to me. He then called a nurse in to take me upstairs and sent mum on her way. Upstairs I was told to strip out of my clothes and shower. I was then told to pick out some clothes from a big sack. I don’t recall ever being assessed by a doctor or nurse. It was not explained to me that I would be getting ECT. It was never explained to me what it was in for and I was never asked to consent to it.”^[440]

196.    Mr Wickliffe told us he was first taken to Lake Alice for ECT treatment from Holdsworth when he was 10. He didn’t know why he was going, and he said when he arrived he was given a cup of brown liquid that made him very sleepy, and he next remembers waking up, “with a throbbing headache and dry mouth in a bed, and the ward was full of people who weren’t moving and had blankets on top of them”.^[441]

197.    Survivors described the dormitories within the villas as hostile. For example, Ms Debbie Dickson who was admitted to the unit when she was nine told us:

“I remember the bedroom that I stayed in. I was all by myself … It had just one bed, with no toilet. As an adult looking back, it reminds me of a prison cell. They would lock me in at night. I remember feeling so scared when the lights went off and the doors were closed for the evening.”^[442]

198.    Overall, most survivors told us the environment was one of fear in the unit. For example, Ms McInroe told us:

“I can recall feeling unsafe. Always unsafe in an unpredictable environment. I recall feeling helpless and hopeless – frightened and anxious of my surroundings and all of the adults around me. Initially I was terrified of everything and everyone. This terror never left – it lessened as I became more and more institutionalised and older and a bit more accustomed to the absurd setting, but it never left.”^[443]

Te noho tahi a ngā tamariki me ngā rangatahi ki ngā pakeke - Housing children and young people with adults

199.    The placement of the unit within the wider hospital meant children and young people sometimes shared the space with adult patients. Many survivors told us they felt frightened of some of the adult patients. In this section, we discuss what survivors told us about being housed with adult patients, and how some survivors spent time in the medium-security and maximum-security units
in the hospital.

200.    Nurse Scholes told us that while the young people lived in villas in the grounds of the wider hospital, it was the intention and practice to keep them separate from the adult patients.^[444] He said, “this was as much for their own protection from some of the more chronic adult patients, as it was for the peaceful enjoyment of the facilities by the adult patients, without being stirred up by the adolescents”.^[445] However, although this may have been the intention, children and young people at Lake Alice were sometimes housed in villas with adult patients.

201.    Until August 1972, no separate facility existed for young people. Mr Marks told us that in June 1972 he was admitted from Holdsworth “through the back door” into an adult villa.^[446] After the first separate villa was opened, the unit was often at full capacity, so sometimes children and young people were placed in the adult villas. Mr Donald Ku was admitted in October 1972 when he was nine.^[447] 

“I was one of the youngest of the children at Lake Alice. There were about eight to ten children in the ward when I was first put in, but there were also adult patients around us all the time, who could have been between 20 and 80 years old. It was very unsafe for us children.”^[448]

202.    Mr Wickliffe, who was admitted in September 1972, told us he moved around a lot of the villas but his first villa “was for criminally insane adults. We were locked in with them and had no protection from violence or sexual assault”.^[449] He said they also shared recreation spaces with adult patients (for example, the garden or during movie nights), which exposed them to greater risks of physical and sexual abuse.^[450] Mr AA also told us that when he was in the unit they had meals in the main hospital with the adult patients from the open side of the hospital.^[451]

203.    The accommodation for girls was always with adult patients, first in the admission ward and later in a wing in the women’s ward. Ms McInroe, who was in Lake Alice in 1975 and 1976, said the villa she was in had three wings that were joined in the middle by an unused nurses’ office.^[452] She noted one wing was for the girls, one was for adult women (some of whom were on remand for criminal offending), and the third held adult male patients (most of whom had been released from the maximum security villa).^[453] She said the girls’ bedrooms were not always locked, and they shared a lounge with the other wings in the villa, so “the reality was that girls under 16 were being housed with adult offenders”.^[454]

204.    Some survivors also told us that staff used the presence of adult patients to frighten and punish them. For example, Ms Collis said:

“Another form of punishment was being taken for walks near the maxi-security. The nurses would make sure it was the men’s exercise time. The nurses would make sure you know they were in there for murder. That was really frightening. They would rattle the fences. You would be scared they could get over the fences.”^[455]

205.    As set out below survivors told us staff used placement in the medium-security and maximum-security villas as a threat and a punishment.

Te kāinga noho whita mōrahi - The maximum-security villa

206.    In the 1970s, the hospital’s maximum-security villa, otherwise known as the National Security Unit (security villa), was Aotearoa New Zealand’s only officially designated psychiatric security institution.^[456] The security villa shared grounds with the Lake Alice Psychiatric Hospital, but was administered separately. Nursing staff were not shared, and patients had to be transferred formally.^[457]

207.    An admission application had to meet criteria demonstrating why an individual needed such secure care and be approved by the Director of Mental Health.^[458] Criteria for admission included an assessment that the patient had a chronic “mental disorder”, was dangerous, had frequently absconded from hospitals and shown destructive or seriously antisocial behaviour during the absence, and had a history of failure to respond to treatment in other settings.^[459] In his letter setting out the process, Dr Mirams emphasised that the criteria were guidelines only, that clinical judgement and experience must be of over-riding consideration, and that not all criteria needed to be met to justify a transfer.^[460] A staff member from the security villa in 1970s confirmed that his understanding of the criteria for admission was that individuals were not admitted unless they had “a major psychiatric disorder” or “posed a serious risk of violence to others” and “the referring hospital or agency was unable to care or manage them”.^[461]

208.    The staff member told us the security villa’s patients aged from 15 to 78.^[462] He also said that because of the proximity of the security villa to the unit, transfers occurred between the villa and the unit and a significant number of young people were housed there.^[463]

Photo of maximum-security villa.^[464]

209.    Some nurses used the fear of transfer to the security villa to threaten patients. Adult survivor, Anne Helm, said the terror amidst the wider hospital of the security villa was “palpable”.^[465] Mr Ku said, “maximum was the place where all the bad people went and got punished. We were all scared of maximum and the nurses would threaten us all the time that we would go there if we didn’t behave”.^[466]

210.    Mr Banks said he was sent to the villa for two weeks in April 1975 for refusing to obey an order by Howard Lawrence to clean the toilet block and the floor with a toothbrush.^[467] He said he was allowed out into a tiny exercise yard for 30 minutes a day and given a few books “but otherwise there was nothing apart from a mattress, blanket and bucket”.^[468]

211.    Dr Pugmire wrote that children and adult patients would have recreation in separate yards, and the children would always be under observation from staff in the tower.^[469] However, Ms Collis, a survivor, recalled seeing a yard about the size of a double bedroom in which adults and tamariki were together and she believed the tamariki were there as punishment.^[470]

Photo of internal exercise yard at the maximum-security villa.^[471]

Photo of cell corridor in maximum-security villa.^[472]

212.    Despite the criteria for entry into the security villa, Dr Leeks noted in a letter to the Director of Social Welfare that it had become a rule that all those who absconded from the unit were placed in the security villa.^[473] In that particular instance, a 15-year-old State ward who had absconded three or four times in a year was placed in the security villa for close to two months.^[474] In 1976, Dr Leeks told the Department of Social Welfare’s Whanganui director, Mr Eric Medcalf, about another boy he sent to the security villa for a month for ‘violence’.^[475] However, another psychiatrist disputed this, saying that after reviewing his file the ‘violence’ consisted of absconding overnight.^[476]

213.    In 1977, Dr Oliver Sutherland from the Auckland Committee on Racism and Discrimination wrote to Minister of Health Frank Gill, about the committee’s concern that a 14-year-old patient was being held in the security villa.^[477] Mr Gill replied that the government was not concerned about the placement of such a young person in the villa, saying the decision about admissions “rests with those who carry the clinical and statutory responsibility”.^[478]

214.    In September 1977, after Dr Leeks left Lake Alice, Dr Pugmire told Dr Mirams that several patients in the security villa had protested the fact three young patients who had been transferred there from the unit were given special treatment by being placed in preferential accommodation.^[479] Dr Pugmire explained they were placed there because he “feared questions might be asked” about their youth and the fact they were being housed there for the Department of Social Welfare, which didn’t have “quite such good facilities”.^[480] Dr Pugmire said the three had been subjected to ‘hugging’ and ‘pawing’ by adults in the security villa.^[481] Another adult patient in the security villa said at one time three patients were under the age of 16 in the villa.^[482] He said he witnessed one boy, aged 14, being sexually abused by an older patient, and a boy aged 16 being sexually abused by older patients on at least three occasions.^[483] He said children were locked up with hardened criminals and sex offenders and did not know why they were there.^[484] 

215.    [REDACTED].^[485] [REDACTED].[REDACTED].^[486]

Photo of a cell in maximum-security villa.

Te kāinga noho whita waenga - The medium-security villa

216.    A medium-security villa was used to house remand patients, ‘difficult patients’ and patients discharged from the maximum-security villa.^[487] A 1977 report found the medium-security villa was ‘grossly overcrowded’, unsuitable for the purpose for which it was being used, and lacked adequate segregation between patients during the days and in the evenings.^[488]

217.    Mr Scholes said patients were generally temporarily transferred to this villa after running away, and the purpose of the transfers was as a reminder that “it was better to be in an open villa than a secure villa”.^[489] He said some of the long-term patients in villa 8 could exhibit behaviours that he can see would have been scary to younger patients (for example, oral outbursts).^[490] He said despite this, all patients in this villa were kept under close supervision to prevent adult patients posing a physical risk to younger patients.^[491] He said he could not recall any instances of an adult patient attacking a child or young person there.^[492]

218.    Mr Banks was 15 when he was put in the medium-security villa, and he found it “a very frightening and scary place”.^[493] He said the risk of sexual abuse meant he had to learn quickly how to keep other patients off him without injuring them, as that would result in a paraldehyde injection as punishment.^[494] Mr Banks said, “I often stayed awake at night, lying scared in my bed with the blankets tightly tucked in, to protect myself”.^[495] Mr Marty Brandt told us he was put into the adult villa for refusing to take medication and was sexually assaulted on the first night.^[496]

Te whakamahinga hē o ngā rongoā - The misuse of medications

219.    Paraldehyde was widely used in psychiatry until antipsychotic medications became available in 1956.^[497] It was mainly used as a sleeping medication or sedative to subdue aggressive or highly excited patients.^[498] It could be injected or taken orally and it had a “strong aromatic odour and a burning, disagreeable taste”.^[499] When injected it was painful and required the use of glass syringes due to its corrosive properties.^[500] The unpleasant odour was also present in people’s sweat, breath and urine after it had been taken.^[501]

Ngā rārangi wheako mō te whakamahinga o te patuhukihuki - Accounts of paraldehyde use

220.    Many survivors were given powerful sedatives such as paraldehyde in the unit. The use of such medications, as well as the threat of their use, contributed to the climate of fear in the unit. Nursing notes show that patients were regularly given paraldehyde and other sedatives such as chlorpromazine between 1971 and 1977.

221.    One survivor described paraldehyde injections as “like having a burning steel bar up your backside”.^[502] Another said it was just horrific.^[503] A third said it felt like boiling water had been poured over the skin.^[504] Many said it left them in pain and unable to walk or sit down for a long time afterwards. Ms McInroe said she received paraldehyde many times by injection, but only once by mouth and it “tasted so foul that I vomited”.^[505] 

222.    Survivors described getting paraldehyde injections to various parts of their bodies. Mr Banks described the injection as initially feeling very cold and then turning very hot, like burning acid.

“The injection would normally be put into the buttocks and the pain would go down my whole leg. It would be very hard to walk. The leg would feel dead and I would have no strength in it. It was painful to sit down for about three days. When I had it in my arm it would hang limp for the day. Once I was given it on the shoulder and on several occasions in the big muscle above my knees. This was particularly painful place to have it and the staff were aware of this.”^[506] 

223.    Many survivors told the inquiry that paraldehyde was given as punishment for things such as kicking a ball at a window,^[507] theft, ^[508] fighting,^[509] smoking^[510] and throwing apples.^[511] Mr Halo told the inquiry “paraldehyde is just like another way of giving us a hiding, the way I see it, but using that injection”.^[512] Another survivor recalled being given paraldehyde after another boy kicked him during a game of soccer and he kicked him back.^[513] He told us a nurse grabbed him by the hair, marched him back to the villa, and dragged him upstairs to one of the rooms, which converted into a cell.^[514] He said the nurse “made me drop my pants and he injected paraldehyde into my backside. It was an intensely painful feeling, and it was very sore. The pain lasted for hours”.^[515] Mr Banks told us sometimes he’d be given the choice between ECT or paraldehyde as punishment.

“Both were used to control us and keep us in fear. The worst punishment was unmodified ECT but Paraldehyde injections were also a feared punishment. You could get a Paraldehyde injection for anything at all such as talking back to staff, hitting another boy, not making your bed properly or not getting up on time. They were extremely painful. I believe I would have had a Paraldehyde injection more than 50 times over my three admissions to Lake Alice.”^[516]

224.    Nursing notes provide evidence that paraldehyde was used more often than recorded in medication charts and sometimes created a clear inference that the purpose was punishment, as the following examples show:

26 August 1974: Throwing apples this afternoon. Paraldehyde 1cc IM given.^[517]

23 September 1974: Misbehaving at school, disruptive and refusing to do as requested. Given Paraldehyde 5mls by injection.^[518]

25 September 1974: This eruptive, aggressive, and hysterical little boy does not appear to have learnt very much from repeated administrations of paraldehyde.^[519]

22 April 1976: Accompanied other boy to steal lollies from the office 2cc Parld.^[520]

7 August 1976: IM Paraldehyde given for kissing and cuddling behind [villa 7].^[521]

19 October 1976: Fighting with [survivor] p.m. 1 cc of Paraldehyde administered as a deterrent for such behaviour in the future.^[522]

14 March 1977: [Survivor] continues to thumb his nose at authority by organising his cig supply. Caught out of bounds smoking after school. Paraldehyde 1cc … given as a deterrent.^[523]

225.    Many staff, including Mr Stabb, Mr Lawrence and Mr Conlan, acknowledged paraldehyde injections were painful.^[524]   They said they administered paraldehyde for a variety of reasons, including “settling patients down that were acutely disturbed”,^[525] “settling down patients who were out of control”,^[526] “to calm people down”,^[527] “to stop violent acting out”,^[528] “for violent or really manic behaviour”,^[529] “as a tranquilizer used in acute psychosis”^[530] and “for control of disruptive or antisocial behaviour”.^[531] 

226.    Ms Leeks, a child therapist at the unit, said paraldehyde might have been used to modify behaviour.^[532] Mr Conlan said paraldehyde injections were part of Dr Leeks’ aversion therapy programme,^[533] and Dr Leeks set out specific guidelines for the use of paraldehyde.^[534] He told us that if sterilised water was not used, the injection would leave a ‘greater sting’, and Dr Leeks’ instructions were not to mix the paraldehyde with sterilised water.^[535]

227.    Mr Conlan said Dr Leeks had written down the criteria for using paraldehyde for aversion therapy purposes, and the criteria and his written authority for its use were kept on the inside cover of the unit drug book.^[536] He said paraldehyde injections were to be given in the upper arm for violent boys or in the thigh for kicking.^[537] Our inquiry was unable to find the book. Mr Conlan said the charge nurse would tell Dr Leeks who had been given paraldehyde and why.^[538] Nurses would make recommendations, based on the criteria, to Dr Leeks about which patients should get an injection.^[539]

228.    Based on our review of the nursing notes, Mr Conlan frequently recorded using paraldehyde.^[540] He later expressed regrets about overuse of paraldehyde, and said he thought nurses had abused the drug simply to curb normal boisterous behaviour. ^[541]

229.    Mr Stabb recalled an incident involving Mr Conlan and a 15-year-old girl who had misbehaved on a school camp in late 1975 or 1976. He said Mr Conlan,

“removed her trousers and gave her an injection of paraldehyde in front of nine other male residents and two other female residents. This was witnessed by … the Lake Alice school teacher at the time, and was during a school camp offsite in late 1975 or early 1976. I remember feeling really disturbed by the incident, both at the indignity of it and the inappropriateness of what had been done”.^[542]

230.    Mr Stabb told us there was a blanket prescription in every ward, signed by the medical superintendent, for intramuscular paraldehyde.^[543] It was to be used in emergency situations (for episodes of violent and aggressive behaviour) where it was necessary to sedate a patient.^[544]  He considered it was well intentioned and designed for the realities of life at the hospital, but that blanket prescriptions gave rise to abuse.^[545] Mr Stabb said such wide discretion would be unacceptable nowadays but was “quite usual” in the 1970s. He told us the use of paraldehyde during his time was minimal and he never used it as a form of punishment.^[546] Mr Hesseltine, Mr Conlan and Mr Corkran similarly said the use of paraldehyde at the unit was minimal.^[547] However, this does not match with the nursing notes we reviewed, which are consistent with the accounts of survivors who said its use was frequent and pervasive.^[548]

231.    Nurse aides, Barr and McCarthy, were critical of the way paraldehyde was used at the unit. Ms Barr said patients were “given paraldehyde injections as punishments for misbehaviour while at the hospital. This rendered them zombies for days, giving them a particular chemical smell, which took days to be excreted from their bodies through the skin, kidneys and lungs. It was hideous”.^[549] Mr McCarthy said if some of the survivors’ claims of abuse were about paraldehyde, then he believed he could “categorically say their claims are true”.^[550] Mr Soeterik said he considered paraldehyde use akin to a ‘chemical straightjacket’ and ‘sledgehammer tactics’.^[551]

232.    In 1976, Dr Leeks received a written complaint from the mother of a boy given paraldehyde injections as punishment.^[552] She said her son told her he was given five injections for bad behaviour.^[553] A charge nurse confirmed to her that the injections had been given as “deterrents” and she said she found it “not only disturbing but mightily displeasing that punitive measures are being used under the guise of treatment”.^[554] Dr Leeks wrote to the mother saying he had looked into the matter, “which rather surprised me, but find that this is not used”.^[555] The boy’s nursing notes record he was given paraldehyde for being “involved in a scuffle”.^[556] His nursing notes refer to his mother’s letter on 25 July 1976, and two days later record that he was given paraldehyde for “skylarking in the dormitory”.^[557]

233.    Correspondence between Dr Mirams and Dr Pugmire in March 1977 shows both regarded the use of paraldehyde at Lake Alice as high. Dr Mirams expressed surprise paraldehyde was still being used with the “degree of regularity implied by the figures you provide” and wished to be assured that Dr Pugmire had given careful consideration to whether it was still “an appropriate psycho pharmacological agent today”.^[558] Dr Pugmire said he, too, was ‘surprised’ at the amount of paraldehyde that had been issued from the Lake Alice pharmacy during the past year.^[559] Dr Pugmire was responsible for the hospital’s national security unit and said injections of tranquillizers (either largactil or paraldehyde) was needed only “two or three times a year” in that unit.^[560] In contrast, paraldehyde was used routinely in the unit and became an integral part of managing patients’ behaviour.

Ngā werohanga patuhukihuki hei whakamamaetanga - Paraldehyde injections used as torture

234.    Some nurses at the unit, condoned by Dr Leeks, administered paraldehyde routinely, excessively and punitively. As with electric shocks, paraldehyde injections that caused severe pain for the purpose of punishment satisfy the definition of torture as outlined by the Solicitor-General.

Ngā wānanga haumanu ā-rōpū i te manga - Group therapy sessions in the unit

235.    Group therapy sessions were compulsory in the unit.^[561] Dr Leeks said initial attempts to get group therapy under way were hindered by his lack of time, disinclination of the staff and, what he termed, the “rather concrete approach to life” by most of the older boys.^[562] However, he said group therapy was used a “great deal” after 1974.^[563]

236.    Dr Leeks said the aim of all therapy was to benefit the children and young people in terms of psychological and emotional growth and to help them cope with their environment outside the hospital.^[564] Dr Leeks considered many patients preferred group sessions to individual therapy.^[565] He said the sessions included some junior staff, a social worker and a visiting educational psychologist.^[566] At the end of each session, Dr Leeks said a discussion and supervision with the staff occurred.^[567] In an interview in 1977, Dr Leeks acknowledged these sessions left patients in tears.^[568] He said “some people see this as treatment and others as punishment. Any emotional thing is aversive, or an emotional pain to the person involved in recalling past bad experiences”.^[569]

237.    Mr Soeterik visited Lake Alice between 1975 and 1977 as an assistant psychologist and later worked as a clinical psychologist at Manawaroa Hospital.^[570] Mr Soeterik said the therapy was ‘confrontational’ and could also be “very tense because nobody wanted to speak”.^[571] He could not recall any patients being made to speak or answer questions.^[572] He also said he did not suggest anybody should get ECT for not speaking up in group therapy.^[573]

238.    Dr Leeks said he and Mr Soeterik were “most involved” in group therapy.^[574] Mr Soeterik said that, although he was in training at the time, he had increased involvement in group therapy as his training progressed.^[575] Other staff recalled Mr Soeterik playing a large part in group therapy.^[576] Five survivors recalled Mr Soeterik running sessions alongside Dr Leeks or on his own. One survivor spoke highly of Mr Soeterik, saying he “was the only one who treated me well”.^[577]

239.    However, many survivors told us they found the weekly group therapy sessions in the unit distressing. Ms Collis told us the process was inherently flawed because the “people who are abusing you are running the group therapy sessions”.^[578] Another survivor said patients would be picked on until they broke down, saying, “I don’t think it was so much therapy as some horrific form of bloodletting”.^[579] A survivor described what these sessions involved.

“Usually Dr Leeks or Vic [Soeterik] would start off by asking one of us particular questions and they all centred around our childhood and our parents and our relationships with our parents and we would eventually [go] along the lines of wanting us to admit, in the case of girls, our father or somebody in the family who had sexually interfered with us. You [would] just be bombarded with questions and it kept up through the whole session until you broke down. It usually lasted from 1 pm till 3 pm.”^[580]

240.    Some survivors also said that if they did not participate in group therapy it could lead to solitary confinement. For example, Ms LL said:

“In these sessions you were supposed to talk about your problems. Everyone used to clam up though. A lot of us didn’t even know what we were in Lake Alice for, so talking about our ‘problems’ was a bit difficult. Vic [Soeterik] was asking questions – I can’t remember what he asked me – and I answered him although I can’t remember what I said either. He then said that it was “an answer”. I don’t really know what he meant but I guess he thought I was being sarcastic. So I was taken upstairs to the solitary confinement room and kept there for about four hours”.^[581]

241.    Many survivors told us that if they did not participate in group therapy sessions in the way the staff wanted, this could lead to electric shocks. One survivor told us Dr Leeks would sometimes point at someone in group therapy, and two nurses would drag them out to have ECT.^[582] Leoni McInroe said Dr Leeks gave her ECT for giggling during group therapy. “He said to me, ‘if you don’t cut it out, you’re going to get ECT’. I apparently did something else to upset Dr Leeks – I cannot recall what. He then said, ‘that’s it … you’re going to get shock treatment tonight’. And I did.”^[583] Mr Richards and Mr AA said patients who did not talk about their problems in group therapy would be threatened with or given electric shocks.^[584]

242.    When faced with the threat of ECT, Mr Richards said he did speak about his past sexual abuse in front of other patients.^[585] After this, two boys who had been in the session followed him and, “when they had the chance, put a hand down my pants. I had the impression that these two boys had learned about my vulnerability at the group therapy and took advantage of it”.^[586]

243.    In summary, the evidence showed that the overall experience of group therapy sessions for most survivors was traumatising and oppressive. Survivors felt compelled to participate and were threatened with punishment if they did not. For some, their participation in group therapy sessions increased their vulnerability and made them a target for physical and sexual abuse in the unit. Evidence from survivors and other staff members showed Dr Leeks and Mr Soeterik played key roles in the group therapy programme at the unit.

Te whakamahinga o te noho taratahi - The use of solitary confinement

244.    Each villa had rooms that could be used for solitary confinement.^[587] Dr Leeks described the ‘destimulation room’ as a bare room with a bed or a mattress.^[588] Another staff member said they were standard rooms that could be locked and had a bucket for a toilet.^[589] A survivor described the rooms in the following way.

“[The rooms] had a single bed with shutters closing off the windows. This room could be used as a security room. The doors were very thick and heavy (oak I suppose) and they had a peephole: a little square window type thing with a sliding shutter across: which could be opened from the outside.”^[590]

245.    The terms ‘seclusion’,^[591] ‘time-out’,^[592] ‘roomed’^[593] and ‘destimulation room’^[594] were all used by unit staff to describe the practice of confining patients to a locked room. Survivors we spoke to predominantly used the terms ‘seclusion’ and ‘solitary confinement’. In this report, we have chosen to use the term solitary confinement, as we consider it more often reflected the practice used in the unit. However, not every situation would meet international legal definitions of solitary confinement.^[595] When reflecting staff perceptions or in quotations we have kept the person’s words.

246.    In 1977, Dr Pugmire said there was a general directive that tamariki should not be detained for longer than 20 minutes.^[596] He also considered that the checking of seclusion and restraint forms by an appropriate body served as a safeguard against patients being “locked up for punishment or for trivial or frivolous reasons”.^[597] Dr Leeks told the 1977 commission of inquiry that patients in the unit were usually placed in confinement for between 20 minutes and two hours to help them ‘de-stimulate’ and it was unlikely they would stay there all day.^[598]

247.    Some staff members we spoke to had similar recollections of how this practice occurred in the unit. For example, Mr Hesseltine told us, “seclusion was not used often and only patients who were physically violent and needed time out. They would only be placed in seclusion for a matter of hours. Seclusion was not used for punishment but to calm patients down”.^[599] Mr Stabb said, “we would usually not use seclusion for longer than an hour. I do recall a couple of occasions where a patient would spend a morning or afternoon in there. Dr Leeks could prescribe seclusion, but I don’t recall it happening”.^[600]

248.    Nursing notes refer to timeframes set out by Dr Pugmire and Dr Leeks. For example, one entry about a seven-year-old survivor says, “He is emerging as quite the little mischief maker whilst with the other boys. Referred to one of the boys as a F____ Bastard, secluded for 15 mins”.^[601] However, many other examples are more difficult to reconcile with their descriptions. For example, the notes for Mr Halo showed he was put in solitary confinement for two days between 21 and 23 July 1976 as a deterrent for perceived uncontrollable behaviour.^[602] Mr Hendrick’s nursing notes recorded it had been decided “to room [him] each night for a week” for “setting up boys, defiant to staff”.^[603]

249.    Survivors describe being put into solitary confinement for long periods. For example, Mr CC was 14 when he was put into solitary confinement after sexually abusing some of the other patients.^[604] He told us nothing was in the room apart from a mattress on the floor and a bucket and it felt “like a holding pen”.^[605] He said he was in solitary confinement in villa 8 and was left alone with no food or water for the first day and night.^[606] He was transferred to the maximum-security villa about two days later, where he was kept in solitary confinement for two to three weeks.^[607]

250.    Ms McInroe told us she was put in solitary confinement on several occasions, and it was always clearly stated that it was for punishment.^[608] She described one occasion where she was in solitary confinement for 21 days.

“That nearly killed me; my spirit, my soul, my wanting to live. I can’t even express what 21 days feels like alone in this world locked in that room knowing that I don’t have anybody on the inside or the outside that cares about me and that these adults can come and inject me and punish me, leave me a bucket to go to the toilet in, and leave me in this little box away from anyone. They were the longest days and nights of aloneness and complete abandonment. A nurse came in at about 15 days when I’d been in there and she snuck me a book and that probably was the only thing that kept me from breaking completely.”^[609]

251.    Survivors told us they were also put into solitary confinement for reasons such as fighting,^[610] absconding,^[611] smoking,^[612] masturbating^[613] and not taking part in activities in the unit.^[614] For example, one survivor told us he was put in solitary confinement multiple times, once for about six days.^[615] The reasons included smoking and masturbating.^[616] Mr Wickliffe told us he was frequently put in solitary confinement.

“Most of the time I was locked away, it was before ECT. I think it was because they did not like to deal with me running around the day room due to the terror of knowing I was about to get it. Other times, I was locked up as punishment for different things like for not wanting to nail together the beer crates we had to make. The longest time I was locked up was for a week.”^[617]

252.    Ms LL said staff used solitary confinement as an enforcement measure, and, “if you didn’t toe the line or do what staff wanted, you knew you would be locked up in solitary confinement”.^[618]

“Being locked up was scary. Horrible. It’s not nice to be locked up. A lot of anger would build up in me, I couldn’t understand why it was happening. There was nothing to do. Time just stopped – it didn’t go anywhere you know? But more than anything, I was scared because I didn’t know what might happen next.”^[619]

253.    Mr Marks said he was put in ‘solitary’ four or five times, each time “for no real reason, just as a punishment because it seemed the staff felt like it”.^[620] He said he was in there for a few hours to a day or so each time but had no food, no water or toilet and no one checked on him.^[621]

254.    One survivor said he would usually have to be wrestled and dragged to solitary confinement and would be put there for just about anything. Mr Scanlon said putting individuals in solitary confinement gave staff an opportunity to physically abuse them “because the rooms were isolated and out of the way”.^[622]

255.    Some staff members’ recollections of solitary confinement practices supported those of survivors. For example, a social worker who visited Lake Alice said she had a vague recollection that “children were sometimes placed in a security room for discipline”, which she considered in keeping with the disciplinarian approach staff took.^[623] It was a view shared by the unit psychologist, Mr Soeterik, who remembered staff telling him they used solitary confinement for periods he considered “excessively long”.^[624] Mr Corkran said “in hindsight, I probably overused the application of seclusion”.^[625]  

256.    We will return to the topic of solitary confinement in the final report, including whether misuse of solitary confinement breaches human rights standards.

Te taitōkai nā ngā kaimahi mahi tūkino - Abuse by particular staff members

257.    Aside from Dr Leeks, the individual staff members survivors said were the most abusive were Mr Lawrence and Mr Blackmore. Survivors reported repeated sexual and physical abuse by both, both used paraldehyde injections as punishment and both helped Dr Leeks give them electric shocks.

Howard Lawrence

258.    Mr Lawrence was born in Canada, trained in Australia as a psychiatric nurse, and worked at Lake Alice from 1966 until 1993.^[626] He worked in the unit for nearly a year when it first opened. Mr Lawrence had no training or experience in working with children.^[627] He was one of the most prolific offenders at the unit. Numerous survivors described sexual assaults and physical violence at his hands, including the use of painful paraldehyde injections as punishment. He was also capable of psychological abuse and assisted Dr Leeks in giving survivors electric shocks. Survivors described him as a cruel and sadistic man.^[628]

259.    On one occasion, Mr EN said Mr Lawrence took a group of patients to an area behind the villas where he showed them an open grave and told them people had been killed and buried there. He said Mr Lawrence told the group he could put them in a hole there and no one would know: “He said he had done it before and nobody knew about it.”^[629] Mr EN told us Mr Lawrence punched him in the head, and he witnessed Mr Lawrence do the same to another boy. He said Mr Lawrence was “particularly horrible and cruel” to patients.^[630]

260.    Mr Christopher Zaal described how Mr Lawrence, Mr Hunt and other staff sexually assaulted him. He said that on six occasions Mr Lawrence dragged him to the toilet at night and raped him.^[631] Mr Lawrence would also grab him by the neck and slam his head into a wall.^[632] Mr Lawrence also told him and others they would “get fried” if they did not do as they were told.^[633]

John Blackmore

261.    Mr Blackmore was employed as a nurse aide in the unit from its establishment until early 1974.^[634] Survivors said he sexually and physically abused them, gave them paraldehyde injections as punishment, and had a hand in Dr Leeks giving them electric shocks as punishment.

262.    Mr Blackmore regularly raped and sexually assaulted Mr CC when Mr Blackmore took him to his home in Marton on weekends. Mr CC said Mr Blackmore would sexually abuse him all weekend and then ignore him throughout the week: “I was so angry with what had happened that about three months into this I started taking my anger out on the other boys by physically and sexually abusing them.”^[635]

263.    Other patients recalled Mr Blackmore taking Mr CC home on weekends.^[636] Mr CC said he complained about the abuse to Mr Hunt but he was ignored.^[637] However, NZ Police were apparently told of Mr CC’s claims because a 1974 court report noted that Dr Pugmire said Mr CC had made “wild allegations” of sexual abuse by staff, which he said “were immediately investigated by the local police who established they were a complete fabrication”.^[638] We could find no NZ Police records of any investigation.

264.    Mr CC’s allegations resulted in Mr Blackmore’s removal from the unit. Mr Scholes recalled Mr Hunt telling him Mr Blackmore had been transferred to another villa because “there had been a complaint that Johnnie Blackmore had been getting too close with the children and had to be moved out of the villa”.^[639] Mr Stabb also recalled hearing years later that Dr Pugmire had removed Mr Blackmore from the unit over allegations of sexual abuse.^[640]

265.    Other survivors also described being sexually abused by Mr Blackmore in the hospital and at his home.^[641] Mr Wickliffe told us he was unable to see his parents on home leave because he was told he had been misbehaving. Mr Blackmore instead took him to his house where he was sexually abused.^[642]

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