663.    The experiences of ‘care’ at Lake Alice constituted systemic abuse. The system failures and factors that contributed to the unit functioning in this way included the abuse of power relations between staff and the children and young people, the physical environment, and the culture of the institution. In addition, no clear pathway existed for complaints about the treatment or abuse inflicted and suffered. Given these factors, robust safeguards were even more critical to ensure the safety of patients at the unit. However, safeguards did not exist or were entirely inadequate to protect children and young people at Lake Alice.

Te kore i rawaka o ngā hōmiromiro, aroturuki nō roto - Inadequate internal oversight and monitoring

Te whakahaere o te manga - Management of unit

664.    Until the 1970s, the Department of Health ran all public psychiatric hospitals in Aotearoa New Zealand. In 1972, the Government transferred control of most psychiatric hospitals to local hospital boards, which had already been running most other public hospitals. This reform was intended to align the mental health system more closely with the general health system. The sole exception to this reform was Lake Alice, which was kept under the Department of Health’s control because the hospital housed the national security unit. This unit was regarded as a government responsibility because it held high-security and forensic patients from around the country.^[1291] In this context, the placement of children and young people at Lake Alice was a serious anomaly.

665.    The Department employed a medical superintendent to run Lake Alice. During the 1970s, this was Dr Pugmire. He oversaw the large number of employees necessary to run a hospital as big as Lake Alice, including psychiatrists, psychiatric nurses, psychologists, cleaners, gardeners and cooks.^[1292]

Te korenga o ngā hōmiromirotanga ā-rata - Lack of clinical oversight

666.    Unlike Dr Pugmire, Dr Leeks worked for the Palmerston North Hospital Board. As one of the country’s few child psychiatrists at the time, Dr Leeks oversaw the board’s child and adolescent mental health services. By an arrangement between the board and the Department, Dr Leeks became responsible for the Lake Alice unit as a consultant to the Department.^[1293] His role included providing specialist advice to Lake Alice staff running the unit.^[1294]

667.    At times this arrangement created uncertainty about the lines of accountability and responsibility. Dr Leeks and Dr Pugmire disagreed about what powers and responsibilities Dr Pugmire and the Department had towards the unit.^[1295] In June 1976, Dr Pugmire wrote to his superior, Dr Mirams, the Director of Mental Health at the Department of Health, asking for clarification about who had administrative responsibility for the unit.^[1296] Dr Mirams responded in July saying the unit was, in many ways, comparable to that of specialised units in a general hospital.

“It is the clear intention and implication of the Mental Health Act that a psychiatrist in a psychiatric hospital should have full clinical autonomy in the treatment of cases under his care. As a corollary of this, he is expected to assume full responsibility in the legal sense… In the general hospital setting it is usual for the physician in charge of such a unit to have full discretion in the matter of admissions to, and discharges from, that unit.”^[1297]

668.    Dr Mirams went on to say that, “[i]t is perfectly true that the physician in this situation is in the general administrative way subject to the direction of the Medical Superintendent of the hospital, just as is a  psychiatrist in a psychiatric hospital”.^[1298]

669.    Based on that advice, Dr Pugmire wrote to Dr Leeks to tell him he (Dr Leeks) was fully responsible and autonomous regarding all clinical aspects of the unit. This included “full responsibility for all treatments by other therapists you may wish to deploy in the unit in your treatment programmes”.^[1299] He continued, “All administrative aspects of the unit will remain my responsibility and I will expect standard procedures to be followed regarding admissions, mental states, follow up notes, recording special investigations, discharge letters and the routine recording and handling of administrative and clerical matters in the same way as they would be dealt with on other wards in the hospital”.^[1300]

670.    A New Zealand Herald article by Mr Peter Trickett on 20 December 1976 said the unit was administered as an integral part of the “non-criminal” section of the hospital,^[1301] and yet Dr Pugmire said he was not responsible for the medical treatment administered to those at the unit because the unit was the responsibility of the Palmerston North Hospital Board. Dr Pugmire expressed surprise the superintendent-in-chief of the Palmerston North Hospital Board, Dr Kenneth Archer, “had also disclaimed responsibility” for the unit, adding, “I thought I was correct in saying that Dr Leeks was responsible to the hospital board that employs him” before concluding, “I suppose he is really answerable to himself”.^[1302]

671.    The magistrate noted the lack of clarity about lines of responsibility between the hospital and the unit in his 1977 report. He described Dr Leeks’ position as “unusual” and continued:

“He is employed by the Palmerston North Hospital Board. Lake Alice Hospital is conducted by the Department of Health. Dr Leeks is seconded to the Department of Health to run the Lake Alice Hospital Unit. Dr Pugmire, the Medical Superintendent of Lake Alice Hospital, told the Commission that he has a written direction not to involve himself in clinical matters in the adolescent psychiatric unit … the unit has nothing to do with the hospital board which is Dr Leeks’ employer. Nor does it come under Dr Pugmire’s jurisdiction in the normal way.”^[1303]

672.    In July 1977, Dr Mirams wrote to the medical superintendents of psychiatric hospitals to “call [their] attention” to the views of the Chief Ombudsman,
but noted:

“The Department does not in any way indicate either approval or disapproval of specific forms of treatment and does not seek to impose any restrictions on the clinical judgement of those with a statutory and professional responsibility for the care and treatment of patients.”^[1304]

673.    This approach to the supervision of treatments at the unit is consistent with the approach taken by the Minister of Health to the Citizens Commission on Human Rights in 1977, where he wrote:

“Treatment of any type is a matter for the judgement of the individual doctor in charge of the case. In terms of the Mental Health Act the responsibility for the treatment of a patient at Lake Alice lies quite clearly with the Medical Superintendent or the specialist psychiatrist in charge of the patient.”^[1305]

674.    However, no means existed to ensure clinicians were held accountable for their statutory and professional responsibilities. In theory, the office of district inspector existed under the Mental Health Act 1969 to ensure agreements to informally admit patients under section 15 of the Act were lawful. In practice, we understand the office was vacant between 1975 and 1978 for the area that included Lake Alice, and no district inspector visited during that period. The failure of the Medical Council process to hold Dr Leeks accountable is dealt with in chapter 2.4.

675.    It is clear no one was responsible for overseeing Dr Leeks’ running of the unit and its activities. Mr Grant Cameron, a lawyer who represented Lake Alice survivors in legal cases between 1996 and 2006, said Dr Leeks was in a position of, “complete autonomy in which he was not subject to any or proper oversight”.^[1306]

676.    Dr Pugmire considered he could not question Dr Leeks’ clinical decisions because Dr Leeks was a full-time employee of the Palmerston North Hospital Board and not on Dr Pugmire’s staff.^[1307] The Department of Health had delegated clinical management of the unit to Dr Leeks, yet the superintendent of Manawaroa did not consider himself responsible for Dr Leeks either.^[1308] Dr Pugmire said that he considered this meant staff at the unit were responsible to no one and Dr Leeks was responsible to himself.^[1309] As a result, there was no oversight of clinical decisions and practices made by Dr Leeks and he was not accountable to anyone.

Te tiaki mauhanga me te tuari kōrero - Record keeping and information sharing

677.    Although Dr Leeks claimed to be implementing a therapeutic aversive programme, appropriate records identifying what he was doing are lacking. Mr Thomas Van Arendonk was the administrative secretary at Lake Alice from 1970 to 1977 and was responsible for all of the records kept at the hospital, including doctor and patient records. He told a private investigator hired by the Crown in 2001:

“I am aware that Dr Leeks was not good on keeping patient records including details of ECT treatment and I discussed this with Dr Pugmire who asked me to speak to Selwyn about this. I approached Selwyn and asked him to ensure that detailed patient records were kept for his own protection and that of the staff. I said to him “look Selwyn we have complaints that you are not recording some treatments.” I reminded him of the interest the Scientology people were displaying in Lake Alice. We had had them visit the hospital and they were shown around and spoke to some of the patients. Selwyn agreed to record all treatments on the files.”^[1310]

678.    Dr Pugmire expressed concern about this, particularly about Dr Leeks’ failure to record his use of ‘electrotonus’.^[1311] He was not alone in this criticism. A staff member, nurse, Denis Hesseltine, told us he did not remember Dr Leeks writing notes regarding Ectonus,^[1312] although in fairness the task of writing notes may have been left to nurses. Mr Stabb told us:

“There were no records kept by Dr Leeks, including records of nursing procedures essential for the safe administration of ECT. Dr Leeks kept medicine charts but I don’t recall ever seeing a medical note written by him in all my time at Lake Alice, in my experience was very unusual.”^[1313]

679.    Mr Stabb said he believed the use of ‘aversion therapy’ at the unit, “was conducted in an air of secrecy, neither being documented, controlled, nor monitored”.^[1314]

680.    When reflecting on the record keeping practices at the unit, Dr Garry Walter wrote in his report to NZ Police that Dr Leeks’ documentation of treatment appeared to depart significantly from the standards of the day.^[1315] He also wrote:

“Although the standards of record keeping were neither as high as they are today and the record keeping was less comprehensive, as a bare minimum one would expect for there to be an entry in the patient file on the day of treatment about the treatment being given and any significant untoward effects experienced following the treatment. Some (but not all) hospitals at the time had a separate form (included in the patient file) that included the date of ECT administration, some information about the characteristics of the electrical stimulus (e.g. on what part of the head the electrodes were applied) and name and doses of medications (anaesthetic, muscle relaxant) used.”^[1316]

681.    Poor record keeping was not limited to Dr Leeks. The Mental Health Act 1969 required every hospital superintendent to keep a register of admissions and discharges (including transfers and deaths).^[1317] We did not find this register for the unit, which is why we are unable to say with certainty how many tamariki were admitted to the unit.

Ngā hātepe amuamu i te manga - Complaint processes in the unit

682.    Almost from the outset, complaints began to surface about the way the unit was treating patients, and nearly all these complaints were swept under the carpet (described in chapter 2.1). Children and young people complained while in the unit and once they had left, but their complaints were, with few exceptions, not believed or disregarded. The barriers to reporting by Māori, Pacific peoples and disabled people are well known. These challenges extend to families. For example, Māori and Pacific peoples may struggle to challenge people in authority, including medical professionals.

683.    Mr Halo had to raise the alarm about the abuse he suffered by writing to his mother in his native language (Niuean) so his plea for help would not be intercepted. Some outsiders such as social workers and psychologists raised concerns, but these too came to nothing. Some staff in the unit raised concerns but were told to mind their own business.

684.    The government organisations with responsibility for various aspects of the unit’s operation – the Departments of Social Welfare, Health and Education – minimised or dismissed the warnings they received and failed to act. They could have done more in the few instances when complaints led to official inquiries.

685.    As with many hospitals in the 1970s, Lake Alice lacked internal procedures for patients to complain about abuse. Despite this, there were several different means by which complaints were or could have been considered. Almost none were effective.

686.    Tamariki tried complaining to staff, without success. Complaints were made to different external agencies, including the Nursing Council, the Medical Council, the Ombudsman, NZ Police, and civil society agencies such as the Citizens Commission for Human Rights (CCHR) and Auckland Committee on Racism and Discrimination (ACORD). Again, with the limited exceptions of the Ombudsman and the interest fostered by civil society agencies, the complaints came to nothing. The statutory offices of the official visitor and the district inspector established by the Mental Health Act 1969 appeared to play no part in the unit.

Ngā amuamu ki ngā kaimahi - Complaints to staff

687.    According to survivors, staff almost never dealt with their complaints in an appropriate way. Staff usually did not believe their complaints, did not seem able to do anything about their complaints, or dealt with their complaints inappropriately. For example, Mr JJ told the inquiry he was regularly sexually abused at Lake Alice by different male nurses.^[1318] One time, he told a trusted nurse about the abuse and showed her a tear on his bottom as evidence. She escalated this information to Dr Leeks, but he said Mr JJ was lying. Mr JJ said he tried complaining to the nurse again on future occasions but, “she would look at me as though she believed me but was saying ‘what can I do?’”.^[1319]

688.    Survivor Paul Zentveld said, “I found that complaining was no use as I had been a mental patient and people would not take me seriously. I had no help with this from my parents. I had been put in Lake Alice in the first place by my mother.”^[1320]  Mr Zentveld said he saw some tamariki complain of being raped then get punished by the staff for complaining. “That’s got to change. The system has to change, there has to be a protection for them somehow … From this psychiatric horror must emerge protections to ensure no child will endure what we have.”^[1321]

Ngā amuamu ki ngā umanga ngaio - Complaints to professional bodies

689.    After he left Lake Alice, Mr Kevin Banks had a complaint referred to the Medical Council. We outline the council process that ended with no charge being laid against Dr Leeks in chapter 2.4. In addition, Mr Stabb, a former nurse, recalled an occasion in 1976 where he helped a group of boys to send a letter to the Nursing Council complaining about the treatment they had been receiving at Lake Alice.^[1322]

690.    In response to a notice from this inquiry, the Nursing Council searched its records and materials at Archives New Zealand, but found no record of any complaint made about the unit or about registered nurses who were staff members at the unit.

Ngā amuamu ki Ngā Pirihimana o Aotearoa - Complaints to New Zealand Police

691.    We detail the complaints made to NZ Police and the failure of each resulting investigation to adequately respond to the allegations of mistreatment of children and young people at the unit over the years in chapter 2.4. An investigation in 1977 focused only on possible violations of the Mental Health Act 1969, which covered harm done to ‘any mentally disordered person’. It is now widely acknowledged that most children and young people at the unit did not have a mental illness. Subsequent investigations were also flawed.

692.    In 2021, NZ Police acknowledged it had failed to appropriately prioritise and resource the investigations. There is also evidence of bias against the complainants based on prior admission to a psychiatric facility. A long history of tension exists between Māori and Pacific peoples and NZ Police. During the 1970s, this tension was evident in the dawn raids of Pacific people’s homes and the occupation of Bastion Point.

Ētahi atu amuamu mō te manga - Other complaints about the unit

693.    The CCHR visit to the unit in early 1976 resulted in a great deal of publicity. Parents started to come forward with complaints about the treatment of their tamariki at the unit. Later that same year, a parent complained to the Ombudsman, which triggered an investigation into decisions and actions of the Departments of Social Welfare and Health in relation to Mr CD. We have described how Mr Halo smuggled a message in Niuean out of the unit with a drawing he sent his mother while at Lake Alice. Because of the media attention by ACORD and CCHR, in 1977 a commission of inquiry was held into the treatment of Mr Halo. Its functions were undermined because the institutions under investigation withheld relevant information from the inquiry.

694.    It was only through the persistence of many individuals and determined advocacy groups that the many allegations of abuse at the Lake Alice unit were eventually dealt with formally by the authorities.

695.    We consider the lack of support in recognising, understanding or reporting abuse likely created an additional barrier to tamariki in the unit disclosing abuse and to the detection of abuse.

Kāore i haumaru ngā kaimahi ki te kōrero (te pupuhi i te whio) - Staff felt unsafe to speak up (whistleblowing)

696.    Nurse Stabb told the inquiry he was often troubled by staff treatment of patients at Lake Alice and thought a lot about saying something. However, he said he signed the Official Secrets Act 1951 when he joined Lake Alice and believed he would be prosecuted for any ‘whistleblowing’.^[1323] He had heard of a nurse in England being deregistered for refusing to help a doctor give ECT to a patient.^[1324]

697.    At the Lake Alice public hearing, Mr Oliver Sutherland paid tribute to educational psychologist Ms Lyn Fry who, he said, risked being seen to have contravened the Official Secrets Act by alerting ACORD to Mr Halo’s circumstances at the end of 1976.^[1325]

Ngā tepenga hōmiromiro, aroturuki nō waho - Limitations on external oversight and monitoring 

Te wāhi ki te tauwhiro - Role of the social worker

698.    Between 1972 and 1974 Mr Hollis was a social worker in a geographic area that included Lake Alice.

699.    Mr Hollis said Lake Alice was ‘a law to itself’^[1326] and didn’t tell social workers what treatment State wards received.^[1327] He said it was ‘odd’ he was not told the specific treatments staff were administering because, as a social worker, he was acting on behalf of the guardian of the tamariki in question, the Director-General of Social Welfare.^[1328] He said in those days, “it was generally accepted that those administering treatment in a psychiatric hospital knew best … the subtle message communicated by staff was not to question them, as social workers didn’t know anything about psychiatric care.”^[1329] He said, “[t]he status of psychiatric professionals in those days was such that they weren’t normally questioned.”^[1330] And added:

“I wouldn’t be overly critical of Social Welfare back then, but in hindsight I think they probably took for granted the care that [State] wards were getting in a place like Lake Alice. I think they assumed all was well and that they were getting highly qualified specialised treatment. They could perhaps have raised more questions.”^[1331]

700.    Ms EE was another social worker who told us about a similar experience. She visited Lake Alice between 1976 and 1977 to speak to State wards and discuss their progress with staff.

“I do not recall Lake Alice staff ever requesting the Department’s permission before giving medications or treatments to children at Lake Alice. This differed from the normal situation with state wards, where the Department’s permission was usually sought before medications and treatments were given …

“… Lake Alice considered it had the necessary authority and expertise to treat the children in the way it saw appropriate, and the input of the Department and others was not seen as important. It was seen as the authority and in a position to make all the decisions.”^[1332]

701.    There was a tension for social workers carrying out their role within the hospital. Ms EE told us she felt the staff at Lake Alice viewed the Department of Social Welfare negatively and had a culture of holding back information from social workers:

When I met with Dr Leeks, Mr Soeterik and Mr Corkran I always felt that some things may have been kept back from me. I remember that there were a lot of side glances and other unspoken interplay amongst the group. This was an ongoing feature of my experience at Lake Alice. At the time, this concerned me and left a question mark in my mind. I felt there was an aura of mystery that I had to break through. I had to show initiative to find things out.

For this reason, I felt my ability to do my job was somewhat frustrated by the unhelpful attitude of some Lake Alice staff.^[1333]

702.    As Ms EE put it, “Overall, I would say that the Department had a presence at Lake Alice but not an authority.”^[1334]  She told us the cultural context was relevant and “[b]ack then, authority was authority and doctors were doctors”.^[1335]

Te wāhi ki ngā kaitirotiro ā-rohe me ngā manuhiri ōkawa - The role of District inspectors and official visitors

703.    At the regulatory level, the Mental Health Act 1969 continued a system of official visitors and district inspectors that appeared in the previous mental health statute.^[1336] These roles were created to provide independent oversight of psychiatric hospitals. District inspectors were lawyers and regarded as watchdogs of patients’ legal and civil rights. Official visitors were non-lawyers who visited psychiatric institutions, supported and assisted patients, and generally kept watch for issues of concern.

704.    District inspectors could receive complaints from psychiatric patients and proactively investigate psychiatric hospitals.^[1337] Their job was to protect patients by making information available on their legal status and rights and to investigate complaints by discussing problems with staff or, in serious cases, referring matters to NZ Police.^[1338] They had a proactive role to check documentation and compliance with procedures, a ‘visitation and inspection’ role, and the ability to conduct inquiries.^[1339] 

705.    The Act did not clearly specify the role of the official visitor, so much individual variation is likely in the way they carried out their role. The Department of Health interpreted the role as acting as a patient’s friend or outsider from the community who could represent the patient’s point of view.^[1340] Official visitors were not paid. District inspectors were paid for any formal or semi-formal inquiries undertaken. However, their inquiries occurred in private and they had the power only to make recommendations, which could be ignored.^[1341]

706.    On the face of it, scope existed for a district inspector or an official visitor to intervene at the request of tamariki at the unit. In practice, neither proved effective monitors of patient rights at Lake Alice. It was the duty of the Director of Mental Health to ensure a district inspector or official visitor visited a hospital at least once every three months.^[1342] The holders of both offices could visit as often as they liked,^[1343] without notice, for as long as they liked, and it was an offence for a superintendent to obstruct a visit by an official visitor or district inspector.^[1344] They could visit at any time of day or night^[1345] and see every part of the hospital and speak to every person detained.^[1346] We are unable to determine whether this occurred, and none of the survivors we spoke to mentioned any interactions with such visitors.

707.    It was mandatory that the superintendent provide the district inspector or official visitor with registers and records required to be kept under the Act and with documents relating to the patients detained in the hospital.^[1347] Every hospital was also required to keep an ‘inspectors case book’ into which the district inspector could enter “such observations as he thinks fit respecting the state of mind or body of any patient in the hospital”.^[1348] 

708.    This inquiry had access to the casebook regarding official visits but only passing mention was made of the unit. In the case of Lake Alice, we understand that no district inspector was appointed from 1975 to 1978, after the resignation of the former inspector. Most of the official visitors and district inspectors appointed under the 1969 Act were Pākehā, despite the increasing number of Māori in psychiatric hospitals and institutions in the late 1960s and 1970s. In a review of the 1969 Act, the lack of cultural responsiveness was acknowledged as an area to be addressed.^[1349]

709.    Deficiencies with the district inspector system were known at the time. District inspectors tended to have only slight workloads under the 1969 Act, something that began to change only in the mid-1980s, then particularly after the Mental Health (Compulsory Assessment and Treatment) Act 1992.^[1350]

710.    Under the modern system, it would be expected that district inspectors allocated to an in-patient unit would exercise proactive powers to identify and report on abuses and breaches of rights. Such a function is particularly necessary where patients may face barriers to making complaints.^[1351] The absence of such activity at Lake Alice was a significant failing. The review also acknowledged that official visitors and district inspectors received no training or orientation to prepare them for these jobs, despite most probably not having any ‘previous acquaintance’ with psychiatric hospitals.^[1352]

Te haukotinga o ngā reta - Interception of letters

711.    In 1977, Dr Pugmire told Dr Mirams he had instructed staff in the unit to censor all children’s letters. Dr Pugmire said this in response to an adult patient who had discharged himself from the hospital but was maintaining correspondence with two young female patients and to safeguard against that sort of activity in the future.^[1353] In his letter to Dr Mirams, Dr Pugmire acknowledged that the Mental Health Act did not permit the censorship of mail and sought Dr Mirams’ advice.^[1354]

712.    We have found that this practice was also used to prevent complaints being made. In August 1975, Dr Pugmire intercepted a letter from a committed adult patient to the editor of The Truth newspaper, in which, he complained about seeing patients assaulted and the treatment of young patients in the unit. The patient wrote, “I have seen young boys of about eleven and twelve here getting shock treatment and dragged back to their villas while they were too dazed to walk after it”.^[1355] In his letter, the patient pleaded with the newspaper, “if you publish this, as you should, as evils in this country’s mental hospitals have gone on too long to be tolerated, then see I don’t suffer any punitive action at the hands of this hospital.”^[1356]

713.    Unfortunately for the patient, Dr Pugmire stopped the letter and on reviewing it, punished the patient by sending him to the maximum-security villa for six weeks. In a note on the patient’s file Dr Pugmire said the transfer to the maximum-security villa was because staff intercepted “a 14-page letter of false allegations”.^[1357] Dr Pugmire also restricted the patient to being able to write to only his adoptive parents.^[1358]

714.    Dr Pugmire passed the letter to Dr Mirams saying the allegations it contained were ‘false and defamatory’.^[1359] Dr Pugmire proposed keeping the patient detained in the maximum-security villa for several more months. Dr Mirams responded to Dr Pugmire, telling him the decision divert the patient’s letter to Dr Mirams breached the Mental Health Act 1969. As Dr Mirams explained, the Act permitted letters to be opened by Dr Pugmire only if he believed “that it may disclose information relating to the mental condition of the patient, not easily obtainable otherwise” or for certain other reasons. Dr Mirams said Dr Pugmire should consider referring the complaint to the district inspector because the patient had made allegations of ill-treatment.^[1360] Dr Mirams also did “not think it appropriate” to keep the patient detained longer in the maximum-security villa.^[1361]

715.    Dr Pugmire referred the letter to the hospital’s official visitor who upheld Dr Pugmire’s decision to stop the letter. The reasons the official visitor cited included that the accusations did not conform to the “known practice of the hospital staff” and that publication of the letter would be “damaging to the good name of a hospital” and would not “enhance the good record of the Department of Health”.^[1362] There is no evidence the official visitor investigated the patient’s allegations.

Ētahi atu āhuatanga hōmiromiro nō waho - Other external oversight mechanisms

716.    As well as the district inspectors and official visitors, the Ombudsman’s and commission of inquiry in 1977 provided a degree of external oversight on specific matters. However, these investigations faced their own limitations (as described in chapter 2.4).

Te korenga o ngā whakaaro me ngā hōmiromirotanga a te mana whenua - Lack of input and oversight by mana whenua

717.    As noted in the report by Ngā Wairiki and Ngāti Apa, there was no opportunity for iwi to provide any input or oversight into the operation of the unit. There appeared to be no consideration of this as an option, despite the iwi having mana whenua over the area and the hospital.

Ngā tūtohitanga - Summary of findings

Ngā āhuatanga i hua ake ai, i whāngai rānei i te mahi tūkino i te manga - Factors that caused or contributed to abuse in the unit 

The Inquiry finds:

• Staff at the unit held largely unchecked power over vulnerable patients. 
• The unit’s isolated physical environment separated patients from their families, culture and support networks. 
• Staff training and resourcing were inadequate. 
• Staff’s prejudiced attitudes devalued patients. 
• The institutional culture at the unit normalised abusive practices and contributed to a culture of impunity. 
• The Department of Social Welfare routinely failed to evaluate whether the unit was an appropriate environment for the children and young people in its care. 
• Internal oversight and monitoring at the unit was inadequate, including ineffective complaint and whistleblowing mechanisms. 
• Complaints to the Department of Education and Department of Social Welfare were not adequately investigated or responded to. 
• External monitoring and oversight mechanisms were limited: district inspectors and official visitors held part-time roles with institutional limitations that reduced their effectiveness.  

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