Taitōkai - Sexual abuse

Te taitōkai nā ngā kaimahi - Sexual abuse by staff members

266.    Sexual abuse was common in the unit. Two nurses, Mr Lawrence and Mr Blackmore, were implicated in many of the allegations of serious and repeated sexual abuse. Another nurse, Mr Brian Paltridge, was jailed in December 1972 for indecently assaulting a boy in the unit.

267.    The application of electrodes and electric shocks to the genitals for aversion therapy was also abuse of a sexual nature by staff.

268.    Ms Collis told us she was raped many times by Dr Leeks in the unit. She recalled these assaults happened after she was injected with an unknown drug and put to sleep.

“I don’t remember a lot of what happened because of the drugs he would inject into me. The first time he did this, I woke up and he was standing at the end of my bed, my top had been pulled over my breasts and my jeans were down to the top of my thighs. He put me back to sleep again and when I woke for the second time, he was gone. I was sore and sticky between my legs. I felt drunk and ready to pass out. I knew that he had raped me.”^[643]

269.    Ms Collis said she complained to staff, but they refused to believe her. One nurse said it was her “imagination playing up”. She said she soon gave up telling any staff about what Dr Leeks did to her.^[644]

270.    Survivors described being targeted in their beds at night by staff, both in the unit and in the adult villas. One survivor remembered hearing other boys screaming in pain while being raped at night.

“Sometimes it was before the nurse would get to me and rape me also. I was so ashamed and embarrassed about what was happening to me sexually, and this embarrassment and shame has stayed with me my whole life. These are horrific memories to live with.”^[645]

271.    Several survivors suspect they were raped while heavily sedated or unconscious after ECT. Mr Richards said he had no idea how long he had been unconscious after ECT, but he “came to back in the cell with a sore, sticky rectum” and believed he had been raped. “I have flashbacks of this but no clear view of the person. I was left in the cell after that ECT for two or three days, cold, naked with one blanket and a bucket for a toilet.”^[646]

272.    Mr Rose said he believed he had been abused after being given a paraldehyde injection, which a nurse told him was something to help him sleep. But it completely knocked him out and when he woke next morning still feeling groggy, he noticed he had a sore anus. “I stuck my hand down my pants and found I was bleeding from the anus. I really do not know for certain what happened, but I suspect Nurse Hunt sodomised me. However, as I was completely unconscious I am simply not certain what happened.”^[647]

273.    Other survivors said staff members threatened them with electric shocks if they didn’t co-operate. A nurse told Ms Shepherd no one would believe her anyway if she complained later and she would be labelled a liar. “He then said that liars get shock treatment around here, or words to that effect.” He raped her, but, despite the pain, she was “too scared to cry out due to the threat of ECT”.^[648]

274.    Mr Banks told us a teacher made him pull down his pants, after which the teacher masturbated himself and then threatened him with “the thunderbolt” from Dr Leeks if he told anyone.^[649]

Te taitōkai nā ētahi atu tūroro i te manga - Sexual abuse by other patients in the unit

275.    Many survivors also told us about sexual abuse by their peers, and how the hospital administration failed to keep them safe. Mr Banks said children were sexual prey for bigger, older boys who “competed with each other to get to us”.^[650] We know that most of the boys with harmful sexual behaviours had themselves experienced sexual abuse, both at the unit and before admission.

276.    One of these older boys was Mr CC, who was 14 when he was admitted to Lake Alice in 1973. Staff at the unit were aware Mr CC, who had been sexually abused by a staff member in a State residence, had a history of harmful sexual behaviour before his admission.^[651] Mr Nicol told us Mr CC tried to sexually abuse him not long after he arrived at the unit.^[652] Mr Nicol told staff about the incident, but he was punished for lying by being given electric shocks.^[653] His complaint was recorded in his nursing notes in the following way, “Has accused other boys of trying to interfere with him. This boy is very cunning, all he wanted was a single room to himself because he hates sleeping in dormitory”.^[654]

277.    We have no evidence to suggest staff took steps to investigate his allegation or prevent further abuse. The next entry in his nursing notes is two days later and records that Mr Nicol was found by staff upstairs on a window ledge and had “threatened to jump out in an effort to be put in a single room”.^[655] An entry the following day recorded that he was given paraldehyde followed by “stern counselling”.^[656] Mr Nicol told us Mr CC continued to abuse him. “A few days later, [Mr CC] raped me. He did this about three times over the next six weeks. When I told the staff, they just laughed and called me a liar.”^[657] Mr Nicol was discharged from the unit in December 1973. In early 1974, following complaints by several other boys in the unit, a report was made to NZ Police about Mr CC and he later faced seven charges of indecent assault.^[658]

278.    Ms McInroe described witnessing sexual abuse in the hall.

“There was a stage in the hall with curtains. I clearly remember someone pulling back the stage curtain, and a girl from our villa was being raped violently on the stage by a boy from villa 7. He didn’t stop even though he was completely exposed, standing facing the hall, facing all of us with her in front of him. Staff pulled him off her. She was so drugged, so defenceless, so completely incapable of protecting herself. I cry again recalling that experience and thinking about her.”^[659]

279.    In April 1976, Dr Leeks told the boy’s social worker he had been “attacking girls”, and as a result was sleeping in a locked room.^[660]

Te taitōkai nā ngā tūroro pakeke - Sexual abuse by adult patients

280.    Many survivors also told us about sexual abuse perpetrated by adult patients of Lake Alice. Much of this abuse occurred when children were housed with adult patients and not supervised properly by hospital staff.

281.    Mr Marks was sexually abused every night by an adult patient in the adult villa he was placed in. He told us the patient “took advantage of the fact I was smaller and more defenceless”. He told nurses about the abuse, but they told him to be quiet.^[661] Mr Wickliffe also recalled frequent sexual abuse by adult patients, saying that they “pretty much had free rein, particularly at night as the nurse only came around once and our dorm wasn’t locked”.^[662]

282.    Other abuse happened during joint social events with patients from the unit and adult patients. Ms LL recalled being groped by an adult patient during a disco. “One of the adults in the ward grabbed me out from the dance floor, took me into a corner and started feeling me up all over. I could see that there were a couple of staff members watching him doing it to me and doing nothing.”^[663]

283.    Ms Debbie Dickson was nine when she was admitted to the unit. She was placed with adult female patients. One evening, staff came into her dormitory to discover an adult female patient sexually abusing her. The woman was then transferred to another villa.

284.    The incident came to the attention of visiting educational psychologist Iain Tennant. Mr Tennant wrote to his superior, Mr David Page, about the way staff had handled the incident. Mr Tennant told Mr Page staff initially planned to “hush up the incident” but at his insistence subsequently notified Ms Dickson’s parents.^[664]

285.    The charge nurse said he discovered Ms Dickson had been sexually assaulted, arranged for her to be medically examined and then called Ms Dickson’s mother and explained what had happened. He said Dr Tisse Siriwardena wrote up a report of the incident and the charge nurse recalled that Ms Dickson’s mother “appeared satisfied with the response”.^[665] A note on Ms Dickson’s medical file confirmed her mother discussed the assault with Dr Siriwardena on 26 October 1978 and Ms Dickson’s mother was assured her daughter had not suffered any “physical injury or harm as a result”.^[666] Within weeks, Ms Dickson was discharged back to the care of her parents because Dr Siriwardena considered “her continuous stay in the hospital in the company of more disturbed children would be detrimental to her”.^[667]

286.    Ms Dickson told us she had no recollection of the assault, although she was upset at how staff had handled the incident:

“How could they do nothing about it? Simply sending me to the doctor for a check and noting that there was no physical harm is not enough. There was no follow-up to see if I was okay after being sexually abused, and as far as the notes are concerned, nothing happened to her. Like I said, I’ve clearly blocked it all out and I guess that’s for the better.”^[668]

287.    Mr Tennant also wrote to Mr Page expressing concern about the safety of young patients at Lake Alice. He said, “boys who have been placed in villa 8 are almost automatically faced with homosexual advances from the adult male patients. Because of their age and inexperience, few of the boys are able to resist these”.^[669]

288.    Mr Tennant said Dr Pugmire responded by building a nurses’ station between the adult wing and the boys’ dormitory.^[670] But Mr Tennant remain unconvinced, saying the basic problem was a lack of adequate facilities so that children and young people were segregated from adults.^[671]

Te mahi uruhi o ngā ārai hapūtanga - The use of forced contraceptives

289.    The hospital administration seems to have been aware that patients in the unit were involved in sexual activity or abuse.^[672] It attempted to use what limited tools it had to prevent sexual abuse, but in practical terms its response mainly consisted of routinely prescribing contraceptives to young women in the unit.^[673] Depo-Provera, an injectable progesterone-based contraceptive effective for about three months,^[674] was the most common. Many survivors told us they were prescribed contraceptives in the unit without their consent. Ms Collis said she was given the contraceptive pill every morning as part of her “medical treatment”. “We were forced to have it, and the nurses would check that we swallowed it. I was not, by consent, sexually active.”^[675]

290.    Another survivor with a learning disability, told us she was admitted to Lake Alice in 1971 when she was 12. “As soon as I arrived I was taken to a room and given an injection to prevent pregnancy.”^[676] She went on to say that she was given ECT many times on each of her three stays at Lake Alice.

“The doctors who administered the ECT were all male and I remember many times when I woke up I was sore ‘down below’. I realised that I had been raped. I specifically remember the tattoo on the wrist of the man who did it to me. I remember telling my mum about it when she visited me but she said it was just ‘growing pains’ and ignored me. I have no doubt at all that I was raped on most of the occasions when ECT was administered to me.”^[677]

291.    A file note by Dr Pugmire about another patient in 1978 acknowledged the practice of prescribing contraceptives to adolescent patients. He wrote that a 15-year-old Dr Leeks had diagnosed with schizophrenia was given Depo-Provera “to avoid unwanted pregnancy”.^[678] Dr Leeks gave another of his patients Depo-Provera because the risk of her involvement with “those of few ethics” could result in her becoming pregnant.^[679]

292.    Prescribing contraceptives was often justified in patients’ files on the basis of their perceived “promiscuity”.^[680] However, a submission by Dr Pugmire to the Department of Justice in 1980 argued that remand patients might prey on “a captive audience of nice innocent good living Christian young women and men who cannot escape from [them] and who are not at their best mentally so that they are ripe for exploitation, misuse and victimisation in every possible way”.^[681] He also said contraceptives “avoid[ed] the embarrassment of having to explain to the respective mothers that they have been fertilised by a passing criminal psychopath. Shortage of psychiatric nursing staff puts a very strict limit on patient supervision and there is not much else that a hospital can do to protect their patients”.^[682]

293.    In summary, the evidence shows sexual abuse was pervasive at the unit and committed by staff members, adult patients and other patients in the unit. The hospital failed to prevent sexual abuse occurring, and when staff became aware of specific instances they often failed to adequately respond. Survivors were often not believed and when it was acknowledged that abuse had occurred allegations were not always referred to NZ Police. The application of electrodes and electric shocks to the genitals at the unit was also abuse of a sexual nature.

Te tūkino ā-tinana i te manga - Physical abuse in the unit

294.    Most survivors told us adults in the unit often treated them with indifference, neglect and callousness. They described physical abuse and violence at the hands of staff, adult patients and their peers.

295.    Many survivors we spoke to told us said they were physically abused in the unit by nurses and other staff. Mr BZ said, “Sometimes the staff would throw us around. They would say ‘well that’s what you deserve’ and ‘take that’”.^[683] Mr Banks said one place where regular physical violence occurred was the “boot room”, the room in villa 8 where work boots were kept. He told us staff would take patients to this room and punch and kick them.

“I was punched in the back of the neck and kicked by two staff. Other patients were roughly treated in there. It was quite obvious as the staff would start on them in the day room and from there take them to the boot room. It could be heard and was talked about.”^[684]

296.    As discussed above, Mr CC said while he was in solitary confinement, Dr Leeks came in to the room by himself and started to swear at him.^[685] Mr CC described Dr Leeks as having punched him in the head, pulled his hair and kicked him several times while he was on the floor.^[686]

297.    Physical abuse happened in the open at Lake Alice. For example, Mr EN told us,

“I remember seeing boys getting kicked in their backs and back sides, and hit on their legs. Once in the dayroom [Howard Lawrence] was sitting in front of a boy like he was counselling him. The boy was sad and [Lawrence] was laughing. Then I saw [Lawrence] punch him straight in the face and knocked him out. He told us we weren’t to look or we would get the same.”^[687]

298.    Mr Rawiri said of staff, “they all just seemed to walk around like [they] were above the law”.^[688]

299.    Some staff members were described by survivors as being particularly violent. Mr Banks said, “some nurses were sadistic and they all participated in the torture of us. Some beat up patients, including me, and some sexually abused patients, including me”.^[689] Mr Ku told us several nurses, especially Mr Lawrence, “would walk past me and kick me and slap me just because they wanted to and just because they could”.^[690] Mr EN told us he was punched in the head by Mr Lawrence at the lunch table for complaining about the food.

“[He] came from behind and struck me on the side of the head knocking me stupid. He said you might like to eat like a pig with your father at home but here you eat with your manners. The other cooks and all the boys present saw me being punched.”^[691] 

300.    Some survivors told us about being physically abused by older patients. For example, Ms McInroe said that she was struck in the head with a heavy metal ash tray stand while she was asleep.^[692] She has a broken optical muscle, and told us the specialists who assessed her for accident compensation found it difficult to determine whether this was due to the severe blow to her head at this incident or an impact of violent seizures during shock therapy.^[693]

301.    Some survivors told us about fighting between the residents of the unit. For example, Mr BZ said, “there was fighting between patients at Lake Alice. Sometimes it would be over smokes”.^[694] Sometimes survivors felt they needed to physically protect themselves from other residents. For example, Mr Richards said scuffles broke out all the time. “I had to always be on the lookout to protect myself from being sexually abused by the other boys. I had to fight them off physically if they tried it on, which they did. That got me into trouble a few times.”^[695] Another survivor said the fights among young people were not necessarily because they didn’t like each other, but because it was a way to release pent-up energy and stress.^[696]

Te tūkino ā-kare ā-roto me te tūkino ā-hinengaro i te manga - Emotional and psychological abuse at the unit

302.    Dr Leeks said the unsuitability of some staff in the unit’s early years was “unpleasantly obvious”.^[697] At this point he said staff tended to have a “demand and obey” attitude towards patients, which resulted in “much interaction between staff and youngsters which was not therapeutic but increased their negative attitudes towards the adult world”.^[698] However, he said new staff were more therapeutically oriented and in late 1974 there was more training for staff.^[699] He believed that within the next two years the unit reached its high point of efficiency, and the staff were dedicated to working with young people.^[700]

303.    Social worker Brian Hollis, like some who gave evidence to us, thought staff were not so much trying to punish patients as control their behaviour. “I’m sure it also made them feel superior to think that the great social welfare couldn’t manage those particular boys, but they could. However, I’m sure they were well-intentioned in doing so.”^[701] Mr McCarthy said at the time he thought most senior nurses “treated the rangatahi with care and respect; some treated them more like family”.^[702]

304.    Some survivors said they recalled some staff members were kind to them.^[703]Another survivor said, “as a kid I couldn’t tell if they were good or bad but they seemed alright. It was only later in life that I realise, looking back, that some of the staff at Lake Alice were corrupt and caused a lot of harm to the kids there”.^[704] Mr JJ said the female staff tended to be kinder to him than the male staff:

“A lot of the male staff were horrible, but Nurse Leonard was lovely and kind and like a mother to us. Mrs Duncan the cook was also lovely and would mother us children. Some of the female staff were lovely, they would give us lollies, kisses, and awhi. Some of the male staff found every opportunity to laugh at us and make fun of us … As children we were told by the male nurses that there were men with guns in the towers and that if we ran away, we would be shot. I believed that.”^[705]

305.    However, most survivors told us staff were cruel to them and inappropriately used their power in the unit. For example, Mr EN told us, “Life was horrific in Lake Alice. The men who were in charge of us did whatever they wanted to us boys there. I didn’t know if they were nurses or what but they had all the power over us. All of us boys suffered under the people in charge”.^[706] Ms McInroe said,

“Most of the staff were cruel. Some were overtly cruel and held back nothing. Some had moments of kindness and tried to be your friend, but they too, happily and without reservation, dished out your punishment, injected you with drugs, locked you in seclusion, were there when you got shock treatment, and denied you pain relief.”^[707]

306.    Many survivors described how staff would regularly belittle them. For example, Mr Banks said, “I was constantly told by staff that I was bad and they were going to ‘drum it out of me’. I was also told that I’d be there for life”.^[708] Ms Shepherd also told us, “I was afraid that I would never leave the place. As patients, we were powerless and had no voice. The staff could essentially do what they wanted to us and they made that quite clear. The staff at Lake Alice reinforced the fact that I was different from others in there. I was constantly ridiculed by staff and patients alike about my gender situation. No one tried to stop this abuse”.^[709]

307.    Ms McInroe described what she called “the daily ritual horrors” of life in the unit of being forced to undress in front of staff for showers.^[710] She said, “Many of them would make humiliating comments about us and our bodies.  They would point out things and laugh and compare naked children and naked adolescents”.^[711]

308.    Threats were a key strategy staff used to maintain control in the unit. Mr Hendricks said that although he did not see anyone being physically or sexually abused while he was at the unit, “We were mentally abused every day though, little comments like ‘wait till Saturday’”.^[712] Saturday mornings were when Dr Leeks would visit the villa and give residents shocks and other punishments.^[713] Ms Dandy described the unit in the following way, “there was fear and terror all the time. The nurses were awful and quite cruel. Sometimes they would taunt us that Dr Leeks was coming … ECT was always used by staff as a threat of punishment to us”.^[714]

309.    Survivors told us about the cruelty of some staff and how emotional and other types of abuse often overlapped. For example, Mr Ku said Mr Lawrence would often take the kids in the woods for walks.

“On one of those ‘walks’ he told me to hold his penis while he pissed. I refused to do that, and he threw me on the ground and pissed on me. When we got back to the villas, he told people I had wet myself, and when I denied it, he got angry and dragged me down the stairs. He gave me to some security men who put me in maximum security. I stayed there for two days.”^[715]

310.    On another occasion, a nurse tasked some children with carrying a person on a stretcher. As they were carrying the stretcher the sheet covering the body slid off, revealing the corpse and a toe-tag.^[716] Mr Banks told us, “I was very disturbed as I had never been around a dead body before. When I got back [the nurse] was laughing and thought it was a great joke, we hadn’t known the person had died. It impressed upon me human life was of very little value at Lake Alice”.^[717]

311.    Ms McInroe said staff bullied patients and some staff encouraged bullying among the children.^[718] She said she joined in sometimes and was “deeply saddened to admit my part in that behaviour”, which was occasionally the result of being “egged on or set up by staff”.^[719]

312.    Some staff members also recalled instances of emotional abuse. For example, Mr Stabb told us he once found a boy tied up in a laundry bag and let him out.

“He wouldn’t speak and wouldn’t move without being led. I attempted to give him a drink, but he could not hold the cup and any water would dribble out of his mouth. When [the nurse responsible] returned from tea, I asked him what was wrong with the boy. He told me that he had behavioural problems and that this was part of his treatment. He returned him to the bag.”^[720]

313.    Teacher, Anna Natusch, considered many staff had a callous attitude.^[721] She recalled one occasion.

“A Māori boy who had suddenly developed greying hair fell to the floor rigidly convulsing, with eyes rolling back in his head until only the whites could be seen. “Just a drug reaction,” said the nurse in charge. “Take no notice. Continue with the lesson!” He lay there, unattended, alone, a lonely, sad and frightened figure, and I went on with the lesson. I never forgot that Māori boy and the suffering he went through. I was helpless to help him and I, too, was touched by the callous atmosphere [and] didn’t really realise the agony he was in.”^[722]

Ngā wheako kaikiri o ngā purapura ora i te manga - Survivors’ experiences of racism at the unit

314.    Māori and Pacific survivors experienced both institutional and interpersonal racism at the unit. The Crown has accepted there was systemic racism at the unit.^[723] The way the unit was run was not culturally informed and there was no respect for Māori or Pacific cultures or incorporation of those cultures into practices in the unit. Survivors were separated from their cultures, languages, and their whānau or aiga.

315.    Māori survivors told us that they were singled out for punishment by staff. Mr EN said Mr Lawrence was “very racist and made this extremely obvious”.^[724] Mr Ku told us Mr Lawrence was particularly known for this. He said Mr Lawrence would “walk past me and kick me and slap me” just because he wanted to, and that he:

“Would do this to all the Māori boys, and I think it was because he was racist. We weren’t doing anything wrong, but he would always pick on us. He definitely treated the Māori boys worse than the Pākehā boys. He would grab the Māori boys by the neck and shake them.”^[725]

316.    Mr Ku also told us of repeated physical assaults by Mr Lawrence, and he felt he was targeted for these assaults because he was Māori. Mr Lawrence gave him electric shocks and urinated on him.^[726] Another survivor, Mr EN, recalled how Mr Lawrence told him that “being a nigga was a reason enough to get paraldehyde”.^[727] He remembered how Mr Lawrence boasted “he could do anything to us that he wanted” and how Dr Leeks’ visits seemed to further inflate his sense of power.^[728]

317.    Another survivor told us he believed “Māori were treated a lot worse than other boys”. In his experience, Māori boys received more electric shocks than the others, and although “we were the minority … we still received the most punishment”.^[729]

318.    While the term ‘institutional racism’ was generally not used by survivors or witnesses when describing Lake Alice, their experiences and reflections show the policies and practices of Lake Alice were not culturally informed, did not allow Māori and Pacific children to maintain their connection to their culture and, worse, punished Māori and Pacific children more because of their whakapapa.

319.    Māori survivors’ cultural needs were not met. One Māori survivor reflected on the impact Lake Alice had on his cultural identity. He explained that his experience in State residential care and Lake Alice separated him from his culture, and as a result, “the source of all my sense of identity and belonging”.

“Lake Alice totally disregarded my Māori culture. I did not have access to any Māori cultural learning as a patient there. Cultural values and beliefs are very important to me and having none of that when I was growing up had a detrimental effect on my wellbeing … I felt like I didn’t belong anywhere.^[730]

“The longer I stayed in Lake Alice and in the Social Welfare system, the more disconnected I became from my Māori culture and more disconnected from my identity. I had a feeling that I didn’t belong anywhere. Where I really belonged was with my mum and dad – with my whānau. When I was removed from that environment, they took me away from my Māori culture. I wish they had given me to my grandmother. I think my life would have been very different if they had.^[731]

“I have suffered, and my kids have suffered because of this racist system.”^[732]

320.    At the inquiry’s public hearing, counsel for the Crown accepted that the unit was institutionally racist against Māori, saying it was clear “there was little or no thought given at the unit to respecting and preserving the mana and tapu of tamariki Māori … Nor was there any provision made in legislative policy and practice settings to kaupapa Māori standards of care or to upholding the Crown’s obligations under Te Tiriti o Waitangi”.^[733]

321.    The inquiry not only heard from survivors about their experiences of institutional racism in Lake Alice, but also heard the reflections of former staff members on this. A former nurse aide at Lake Alice, Mr McCarthy, sharing his insights, said he did not notice any different treatment but did note there was an “absence of understanding of different cultural needs for Māori patients”.^[734]

322.    Further, he said the way Māori view health and wellbeing, and the importance of that view, was not considered. Mr McCarthy also noted he found it unusual he saw “very little involvement of whānau in the lives of rangatahi” while they were in the unit.^[735]

323.    Mr Wikepa Keelan, a nurse at Lake Alice from 1974 to 1978, shared similar sentiments. He said while initially he did not notice how services treated Māori differently, as it was the “accepted status quo”, he soon realised mental health and addiction services were “out of synch” with Māori.^[736]

“This is evidenced by Māori having poorer health outcomes and increasing inequity across the Mental Health and Addiction system nationally. Although at the time there was not much evidence to draw on, the impact of the unlevel playing field is clear today …

… the system is failing Māori and there is good evidence of inequity across Mental Health and Addiction services to prove this. For example, some Māori patients came into the hospital affected by Wairua illnesses which were largely disregarded or misunderstood by the clinicians.

That clash between Māori cultural requirements and Western clinical imperatives is still alive and well today, fuelled by conscious and unconscious biases, and is the reason why the Mental Health and Addiction national system is not working for Māori. The evidence for inequity and poor Māori health outcome is evidence all across the health system including the Mental Health and Addiction service.”^[737]

324.    Pacific survivors also experienced racism in the unit. Mr Scanlon, a Samoan survivor, told us:

“At that age, I didn’t really know what racism was … Looking back on my time at Lake Alice, it was clear that the Polynesian and Māori kids were treated worse than the palagi kids because we were getting more injections and electric shocks than the palagi kids. There were rules for them and different rules for us.”^[738]

325.    Before his admission to the unit, Mr Halo had been at an intermediate school where he was put in a special unit for children learning English as a second language. At Lake Alice, he received no language support. This was particularly damaging because, as Mr Halo noted, “my problems started from me being unable to speak English”.^[739]

326.    Long-time social justice advocate Dr Oliver Sutherland said at the inquiry’s public hearing that the story of Mr Halo exemplified the institutional racism prevalent in the 1960s and 1970s. He said Mr Halo was labelled handicapped and violent because he struggled to speak English and lashed out when teachers punished him for his poor performance. Dr Sutherland said the way Mr Halo was treated showed a glaring failure of the institutions that dealt with Mr Halo and his family, in particular, education, NZ Police, youth court, social welfare and health institutions.^[740]

327.    Mr Halo was admitted to Lake Alice from Ōwairaka Boys’ Home on the assumption he was already a State ward, but he was not. He was sent to Lake Alice through a combination of miscommunication and deception. He said his parents were told he was being taken to Lake Alice to go to a school there, and they were not told it was a psychiatric hospital, “They never knew the true story”.^[741]

328.    He said he had been able to contact his mother and tell her about the electric shocks and injections, but she did not know how to get help or intervene, mainly because English was her second language and she could not call on any Niuean interpreters. “She felt that, because I was in the State’s hands, there was nothing she could do.”^[742]

329.    The Crown accepted the Pacific patients in the unit experienced institutional racism. It acknowledged that “there was little or no attention devoted to considering the difficulties that Pacific patients faced in the totally alien environment that neither recognised nor respected their culture, their languages, or their relationships with their families”.^[743]

Ngā wheako whakatoihara hauā o ngā purapura ora i te manga - Survivors’ experiences of ableism at the unit

330.    Many disabled children and young people were admitted to the unit, including those with a learning disability or neurodiversity. However, we are unable to give precise numbers due to poor record keeping and issues with inappropriate diagnoses.

331.    Discriminatory attitudes towards disability contributed to survivors’ admissions to the unit, and many survivors also experienced ableism in the unit. This affected both survivors who identify as disabled and survivors who don’t, but were perceived to be disabled by the hospital or other authorities.

332.    Many survivors told us that receiving a diagnosis of disability contributed to their admission but did not mean they, or their family, received extra support. For example, Mr Ku told us he does not think he was disabled when he went into the unit. “I was just a young boy struggling with being brought up in a hard environment.”^[744] He said his parents were struggling too, but instead of helping, hospital authorities diagnosed him with learning disability and “got me locked up”.^[745]

333.    Survivors’ experiences of racism and ableism intersected. For example, Mr Halo moved to New Zealand with his parents from Niue when he was six years old and did not speak English when he arrived.^[746] He told us he did not understand what was happening in school. “I think because I didn’t speak in class, they thought I was handicapped.”^[747] He said that he later changed schools and was put into a special class, where he felt out of place, became restless and bored, and got into trouble.^[748] He told us the State and schools needed to do more to help people from different cultures, especially if English was their second language, because his problems started from not being able to speak English.^[749]

334.    Mr JJ had a learning disability that meant he struggled to learn how to read, write or spell.^[750] He said this was made worse by stress he was under at home and that his primary teacher would hit his desk with a cane and shout at him for not being able to do the work.^[751] He said he got teased and made fun of at school and at home for his difficulties learning.^[752] He would lash out and hit children who were teasing him, which led to his reputation for being aggressive and then to his admission to the unit.^[753] Mr JJ said Dr Pugmire wrote a psychiatric report that was both insulting and led to his being taken away from his family, made a ward of the State and, eventually, admitted to the unit.^[754]  Dr Pugmire’s report, which recommended Mr JJ be admitted to Campbell Park, a residential special school, said:

“This 12-year-old Māori boy is one of a family of sub-cultural, subnormal children born to an irresponsible Māori mother by an unstable violent father. His IQ is in the 75 to 85 range, but his behaviour at home and at school suggests not only low intelligence, but a gross instability or early psychosis.”^[755] 

335.    Some survivors were never told why they were admitted to the unit. Others said their parents told them they needed a break^[756] or that there was nowhere else for them to go.^[757] A survivor who told us she was born with a physical and learning disability said her parents had told her sister, “sending me to Lake Alice was ‘the best they could do with someone like me’”.^[758] It is clear whānau were not told what would happen in the unit. For example, Mr BZ said his grandparents decided the unit “would be the best place to help with my epilepsy”.^[759] They were finding it hard to look after him and told him he would be safe: “They did not realise it was a bad place.”^[760] He spent nearly a year and a half in the unit.

336.    Once in the unit, many survivors experienced ableism. For disabled survivors, and survivors who needed additional support or accommodation, they were placed in an environment that misunderstood and ignored their needs. For example, Mr Nicol told us, “I had a disability. Instead of love and care and help with it, I got cruelty and torture and was made to feel a worthless human being.”^[761]

337.    All the children and young people admitted to the unit became vulnerable to an environment that stripped them of any control or influence over their own lives or circumstances. Children with disability experienced increased risks of abuse and neglect due to a complex variety of societal factors, including a lack of adequate support to identify and report abuse.

338.    Accounts from disabled survivors show little thought was given to accessibility, additional support or accommodations. For example, Mr Mathieson-Ngatai told us he remembered a boy who was brought to Lake Alice from Kimberley who used a wheelchair and was made to sleep downstairs, because the dormitories were upstairs and inaccessible.^[762] Mr Antony de Malmanche has mild brain damage, which meant he had trouble remembering and learning new things growing up.^[763] He told the inquiry he remembered having a brain scan while at the unit, which showed the damage and that his brain had been deprived of oxygen, and Dr Pugmire gave him his diagnosis of brain damage.^[764] However, he told us, “I never got treated for this. I was always treated like my problem was just abnormal behaviour and I was punished accordingly”.^[765]

339.    The knowledge that some of the unit’s patients had la earning disability should have prompted staff to make sure they were communicating and explaining what was happening in the unit in a way that was appropriate to survivors’ needs. Instead, the disabled survivors who spoke to us were often confused about what was happening to them in the unit. Many disabled survivors we heard from expressed confusion about why they were admitted to the unit. One said he was simply put in a car and onto a plane without understanding what was happening.^[766] Many survivors have also expressed confusion about why they received shock treatment and paraldehyde injections in the unit, because it was not explained to them by staff. We also heard evidence that survivors with learning disability were punished for not understanding staff instructions. Mr DT said the male nurses used to hit him for not listening to them. “They hit me all over – in the stomach, anywhere they were capable of. One time, five or six nurses hit me in the tummy using their fists … I would be told off … quite a lot.”^[767] 

340.    Most disabled survivors told us their education suffered badly while in the unit. For example, Mr Mathieson-Ngatai attended Homai College before being admitted to Lake Alice. He said, “when I went to Homai College I could not read or write. I was beginning to go completely blind, so I went to learn braille. I quite liked Homai College. It was good being taught how to read braille”.^[768] When Mr Mathieson-Ngatai attended Lake Alice school, he did not have access to braille, instead he would be asked to read printed text using a magnifying glass, which severely limited his ability to learn.^[769] This neglect affected survivors’ literacy and greatly restricted their developmental opportunities in other aspects of their lives.

341.    Staff in the unit appeared to have little expectation disabled survivors would have positive outcomes. Many of the disabled survivors we heard from did not go to school at all during their time in the unit. For example, Mr BZ said he did not go to school at Lake Alice. Every day, he would walk around the block and for the rest of the day he would sit around.^[770] The disabled survivors who did attend school faced significant barriers that inhibited their ability to learn. They said there was too much focus on craftwork and too little on things like mathematics.^[771] 

342.    Some disabled survivors remained in residential care after their discharge and continued to have limited access to educational opportunities. Others were discharged from the unit and went to schools, although the disruption to their education while at Lake Alice and limited support in their new schools, restricted their ability to resume learning. Mr de Malmanche, who spent two years at
Lake Alice, said,

“I was so far behind my peers when I got out. I went into fourth form at high school, and I didn’t have a chance. Of course, my mother expected me to be up to speed with everything and pass my school certificate. It wasn’t going to happen.”^[772] 

343.    Falling behind educationally during crucial developmental years has had life-long consequences. Mr JJ spent 10 months at Lake Alice but did not attend the unit’s school during his time there. Instead, he was “put to work making pot plant plaster casts and other things”.^[773]  

“Most of my life, I was not able to find a job. No one would take me on after they asked about my education and found out I couldn’t read or write. Also, I have just not been well enough to work for most of my life. I believe I lost the chance to earn a living because of Lake Alice and Cherry Farm [a psychiatric hospital].”^[774] 

344.    Mr DT went to school near Lake Alice instead of attending Lake Alice school. He told us that his school, “was a lot safer with more protection from the other boys … The teachers would treat the students differently – treat them fairly. At Lake Alice, they treated you unfairly”.^[775] 

345.    Disabled survivors’ health needs were also neglected. Some survivors told us they received medical treatment in the unit that was unsuitable for their disability and sometimes made their situation worse. Three individuals at the unit – Mr Mathieson-Ngatai, Mr Halo and Mr BZ – had a history of childhood epilepsy. All three received shock treatment for the condition. Mr Mathieson-Ngatai said it did not help, and his epilepsy improved only after leaving Lake Alice and receiving proper medication.^[776] Mr Halo said ECT reactivated his epilepsy, after he’d had no symptoms for years.^[777] Mr BZ said ECT made his epilepsy worse.^[778] 

346.    We found disabled children and young people were more at risk of receiving shock treatment and experiencing medication abuse, sexual abuse, physical abuse and psychological abuse in the unit. Most received shock treatment, were given paraldehyde as punishment, and were given other medications without knowing what these were for.

347.    Many disabled survivors told us they had been physically abused. Mr Mathieson-Ngatai said, “when I had epileptic seizure, I would shake, and staff would come along and kick me in the guts”.^[779] Survivors also told us of numerous instances in which staff abused disabled children and young people in front of others. Mr Nicol said,

“I will always vividly remember once at meal time a mentally disabled boy was masturbating under the table, and all of a sudden, a staff member came over and injected him in his penis, right there in the dining room. I was at the same table and saw the whole thing. The boy screamed the most horrifying screams I have heard apart from those of us having ECT. It was the most horrible thing. It is one of the memories that won’t go away.”^[780] 

348.    Many disabled survivors shared their experiences of sexual abuse in the unit. The abuse usually happened many times and sometimes involved multiple nurses. One survivor said a staff member witnessed him being sexually abused and simply turned his back. When Mr Nicol reported to staff that another patient had attempted to sexually abuse him, the staff member accused Mr Nicol of lying and punished him with electric shocks.^[781] 

349.    Psychological abuse, in the form of threats and bullying, came from staff as well as other patients. Mr BZ said that he would get teased by the other patients. “They would make up silly stories about me. I would sulk because of it. Because I was sulking all the time I would get put into lock up.”^[782] Mr DT, who has a learning disability, said the other children would call him names. “I don’t think it’s worth me repeating what they said. This made me feel bad. I didn’t cope with it well. I just wanted to hit them.”^[783] He said some of the boys would bully him and explained that one way they did this was to repeatedly strip the bedsheets off his bed, eventually he got sick of it and yelled at them.^[784] 

350.    Mr DT said, “I would be told off more than often – quite a lot. They kept a diary for bad behaviour and I was in it lots. I would get in there for hitting and lashing out.”^[785] Mr DT went on to say, “If you got told off, you would go into the lock up room for the day. You would spend the night in the lock up room, until the next morning. This happened to me several times and different people as well as me. Once or twice, I was in the lock up room for more than the day. It was a lonely space.”^[786] He said that Dr Leeks and Dr Pugmire also weren’t very kind to him, “they treated me unfairly. Pretty much similar to the way the kids treated me”.^[787] 

351.    Another survivor, Mr Steve Watt, witnessed Mr DT being bullied and said that no matter how badly the bullies taunted Mr DT, they were never punished as much as Mr DT was for responding to their taunting.^[788] 

Ngā wheako mae takatāpui, mae irawhiti o ngā purapura ora - Survivors’ experiences of homophobia and transphobia

352.    Many survivors experienced homophobic and transphobic abuse at the unit. This affected some survivors who now identify as part of Rainbow communities and others who don’t. Discriminatory attitudes against members of Rainbow communities contributed to some survivors’ admission to the unit and the abuse they experienced there. In this section, we discuss how homosexuality was considered a problem to be ‘treated’ and that Dr Leeks used electric shocks as part of this ‘treatment’. In addition to these conversion practices, survivors were punished for behaviour that staff considered ‘homosexual’ and for failing to conform to traditional gender norms.

353.    Behaviour that reflected diversity of sexuality, gender identity or gender expression was often a basis for admission into the unit. For example, boys who were perceived as feminine, wearing women’s clothing and using make-up. One State ward was admitted into Lake Alice for 10 months following concerns he preferred girls’ clothing and had ‘feminine mannerisms’.^[789] 

354.    Once children and young people were in the unit, homophobia and transphobia contributed to the abuse survivors experienced there. Sometimes this was because clinical staff believed behaviour that might reflect diverse sexuality, gender identity or gender expression was something that could and should be ‘treated’. In other cases, it was regarded as something that needed to be suppressed through punishment.

355.    Evidence shows that Dr Leeks believed sexual identity was determined at an early stage and was reversible only up to a certain point. When discussing the treatment of one patient in October 1972, Dr Leeks wrote, “As regard to his homosexual trends, these may not be reversible as one’s sexual identity is determined from a fairly early age and added to within the first five to seven years of life. Subsequent events only emphasise that which was already there”.^[790] When discussing the unsuccessful treatment of another patient, Dr Leeks wrote, “It is unfortunate for him, but by now his effeminate identity appears immutable”.^[791] However, Dr Leeks still attempted to change his patients’ sexuality.

356.    Dr Leeks used aversion therapy to ‘treat’ behaviours labelled as homosexual.^[792] In 1977, when he gave NZ Police a list of patients who had been given aversion therapy in the unit and the reasons why, the reasons listed included ‘homosexual activities’.^[793] The drug paraldehyde was also often given to tamariki in an attempt to suppress behaviours perceived as homosexual. One survivor’s nursing notes record an incident where three boys were caught “half naked, playing a perverse game of spin the bottle”. The notes record the boys were injected with paraldehyde and put to bed.^[794] Another survivor’s nursing notes state the main objective for heavily sedating him was to prevent him making advances on other boys in the villa.

357.    Solitary confinement was another tactic often used to both keep boys caught engaging in sexual activity away from one another and punish survivors for behaviours that did not reflect traditional gender norms. The nursing notes of one survivor state he was “roomed for the duration of the day as he has been caught applying eye-liner to his eyebrows during school”.^[795] 

358.    Dr Leeks was not alone in his belief that homosexuality could be “cured”. Dr Pugmire believed his own conversion practices were successful. He wrote in a letter in 1974, “For the past 10 years or so I have been putting all my Sexual Deviants and Homosexuals on Melleril,^[796] usually at the rate of 25mg tds [three times daily]. Sometimes as much as 50mg tds. I’ve never seen a Schizoid case of homosexuality who continued the treatment for 12 months without ceasing to be a homosexual”.^[797] 

359.    Homophobia and transphobia also contributed to children and young people perceived to be homosexual being more at risk of unreported and unaddressed sexual abuse. In a file note, Dr Leeks wrote about how Mr CC, a unit patient, had previously been repeatedly sexually abused by a staff member at a State residence.^[798] Instead of identifying this as sexual abuse and treating Mr CC as a survivor, Leeks referred to the incident as Mr CC having been “involved in homosexual behaviour with a temporary house-master”.^[799] This attitude placed the focus on the child’s perceived sexual orientation, rather than the fact he was a vulnerable child who had been abused by an adult.

360.    Survivor, Sharyn Shepherd, told us, “The staff member [who raped me] started to talk to me. He told me how pretty I was. By that time I was 14 years old and very feminine looking. He showed me the shock treatment machine and the electrodes, explaining how they attached to your head when ECT was administered. He then threatened me with shock treatment if I didn’t co-operate”.^[800] 

361.    Homophobic and transphobic verbal abuse was also a normal occurrence in the unit. One survivor said he and another patient were called homophobic and transphobic slurs by staff and patients. Ms Shepherd told us that staff and patients “constantly ridiculed” her because of her intersex status.^[801] Anne Helm, who witnessed the bullying of one survivor, told us he was “the subject of taunts from the other adolescents”, adding that “he had bobbed shoulder length hair and being gay in that place at that time meant he really had no group or place that he belonged”.^[802] 

362.    Homophobic and transphobic abuse in the unit had a profound impact, causing lasting harm to those targeted. This affected not only patients who identified with the Rainbow community, but also tamariki staff perceived as being homosexual or transgender or who had a gender expression that differed from traditional gender norms. In addition, this abuse caused psychological harm to the direct recipients of abuse and to any other children and young people in the unit who were questioning or uncertain about their sexuality or gender identity.

Ngā tūtohitanga - Summary of findings

Te āhua me te rangiwhāwhātanga o te mahi tūkino i te manga - Nature and extent of abuse at the unit 

The Inquiry Finds:

• Extensive tūkino - abuse, harm and trauma - at the unit included: 
  • electric shocks as punishment, administered to various parts of the body, including the head, torso, legs and genitals 
  • the injection of paraldehyde as punishment  
  • physical and sexual abuse by staff and other patients 
  • the misuse of solitary confinement  
  • emotional and psychological abuse 
  • exposing patients to unreasonable medical risks. 
• Survivors experienced systemic racism, ableism and homophobia in the unit. 
• The use of electric shocks and paraldehyde to punish met the definition of torture as outlined by the Solicitor-General.

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