Te tūkinotanga i ngā whakaritenga Turi, whaikaha, whaiora anō hoki
Abuse in Deaf, disability and mental health settings

671. Deaf, disability and mental health settings include larger-scale institutions such as psychopaedic and psychiatric hospitals, smaller-scale care and support settings and services, including group homes, and special education settings. While all forms of abuse were experienced across most disability and mental health settings, this section focuses on the most pervasive and unique forms that the Inquiry has heard about.

672. The Inquiry observes that across the specific sub-settings, the harmful nature of the environments and the types of abuse within them were similar. The Inquiry heard that all disability and mental health settings were environments of isolation, fear, violence and control for many survivors and witnesses.[982] Features of these settings included:

• strict regimented routines
• a lack of personalised care and instead focused on providing a uniform approach delivering the same services to everyone in care regardless of age, gender or sexual identity, abilities or needs
• people in care experiencing depersonalisation, for example people in care being processed in groups according to fixed timetable, without consideration for individual privacy needs
• one size fits all approach, institutional care follows a uniform approach, providing the same services to all children, young people and adults in care regardless of their age, gender, abilities, needs, or reasons for separation from parents / caregivers
• isolation from whānau, children, young people and adults in care in institutions are often isolated from their whānau, support networks, hapū and iwi, and communities, far from their places of origin, and unable to maintain relationships with parents, whānau and support networks.

673. Children, young people and adults in Deaf, disability and mental health care settings experienced physical abuse that was violent, pervasive, and created a climate of fear for many survivors. Most of the abuse that occurred was perpetrated by staff, and in many instances the abuse was intentional. Some abuse was perpetrated by peers of the survivors, and some by other people with staff allowing or facilitating the abuse.

674. The Ministry of Health acknowledged the presence of physical abuse in disability and mental health care settings from 1950 to 1999 and recognised that during this time, these care settings did not always adequately safeguard people from harm.[983]

675. Survivors and whānau told the Inquiry that the most pervasive form of abuse in these settings was neglect,[984] with the denial of an individual’s personhood being an insidious and damaging feature of all disability and mental health settings. Personhood has been described as the “essence of being human” and includes “choice, a sense of autonomy, being part of a loving family, the chance to labour, love and consume”.[985]

676. Many survivors told the Inquiry they were physically abused by other patients or residents at institutions. Peer abuse inside institutions was widespread, recurrent and often not dealt with by staff. Survivors described being hit in the head and knocked out by a cricket bat, bitten, stabbed in the stomach and thrown downstairs by their peers.[986]

677. Almost all survivors described abuse and neglect that stripped them of their personhood, identity, dignity, and autonomy. This abuse and neglect represented a disregard for the inherent human value of blind, Deaf and disabled individuals, disrespect of their diverse identities and needs, and a failure to fulfil their rights to participation, inclusion and decision-making. This abuse also represented a disregard for the collective whakapapa rights of survivors whānau, and a failure to support their rights to participate in the decision-making of their whānau member in care.

Te tūkinotanga i ngā whare taurima hunga mate hinengaro me ngā horopaki hōhipera mō te hunga whaikaha
Abuse in psychopaedic, psychiatric and hospital settings for people with physical disability

678. The bulk of evidence received on disability and mental health settings relates to the large-scale institutional environments discussed in this section, particularly prevalent until the latter 20th century.

679. The biomedical model of care influenced institutional responses towards disability, difference and diversity. Medicalisation shaped the nature of the residential environments, the power dynamics within them, and the experiences that people had within these settings.[987] Medicalisation overlaid much of the abuse perpetrated in these institutional settings, allowing for the justification of abusive and dehumanising practices, and enabling resources within the medical environment, such as medication, equipment and spaces for solitary confinement, to be used in harmful ways.

680. Dr Olive Webb highlighted the powerlessness of people placed into these institutions compared to staff:

“The systems in which everybody lived and worked were terribly cruel, because you had one group of people who had the power of life and death and daily activity, and every single piece of power that you could wish to have, completely dominating another group who had absolutely no power at all. They didn’t decide what they ate, what they wore, where they went, or anything, they were simply – they were required to be obedient.”[988]

681. Mark Benjamin, former chief executive of Standards and Monitoring Services New Zealand, echoes what the Inquiry learnt from survivors who were in large-scale institutions when he stated: “The impression for many of us working in the [disability] sector is that it is unlikely people would leave an institutional or faith-based setting without being abused or assaulted in some form or another.”[989]

682. Counsel for the Crown Secretariat described the evidence presented at the Inquiry’s Ūhia te Māramatanga Disability, Deaf and Mental Health Institutional Care Hearing as “a shameful picture of inhumanity”.[990] This is an apt description of what was experienced in these settings.

Te whakahapa, te whakahāwea me te taunu
Neglect and dehumanising and degrading treatment

683. Society’s attitude of devaluing disabled people and people experiencing mental distress, was concentrated within the confines of institutional settings. Staff viewed and treated individuals in their care as ‘less than’[991] – many survivors talk about staff failing to provide residents with even a basic level of respect and dignity.[992] For example, survivors shared it was common for psychopaedic nursing staff to use fire hoses on disabled people in their care if they were incontinent.[993]

684. Survivor Carla Mann, who spent part of her pregnancy in Carrington Hospital in Tāmaki Makaurau Auckland said: “You weren’t treated like a person there, you were treated like a ‘thing’.”[994]

685. In September 1986, two nursing tutors formally documented their concerns about the treatment of residents by staff at Templeton and filed their report with the Canterbury Hospital Board. Among the concerns raised was that “many staff demonstrate lack of respect for the dignity of the people who are placed in their care by trusting relatives”.[995]

686. A lack of physical privacy paired with highly regimented daily routines was common in psychiatric and disability institutions and contributed to survivors’ feeling of a loss of dignity and personhood in care.[996] Many survivors said there were few or no private spaces within institutions. Individuals were typically expected to use the bathroom, get changed, and shower in front of peers and staff.[997]

687. Dr Olive Webb described the morning routine of a villa at Sunnyside Hospital in Ōtautahi Christchurch housing about 70 men. The routine involved being stripped naked, marched from their villa, herded into a large bathroom with multiple shower heads, and showered as a group by staff wearing rubbers and gumboots. These men were then dried and herded back naked to be dressed. When asked what this routine reminded her of, Dr Webb said “concentration camps came to mind”.[998] She remarked that when she visited the wards at the Templeton Centre located near Ōtautahi Christchurch, a psychopaedic hospital, many of the residents were naked. When people shared the toilet pans, they were all in one room. The staff who worked in that ward called it the “milking session”.[999]

688. Survivor Denise Caltaux similarly described the lack of dignity and care afforded to patients at Tokanui Psychiatric Hospital in the early 1990s, describing it as 'horrendous'.[1000] Denise recalled that patients in the unit at Tokanui were “herded like animals” to be locked in a communal space during the day, showers were conducted communally by gender each morning, and there were no choices given around food and drink.[1001]

689. A report about Tokanui Psychiatric Hospital in 1985 concluded:

“Residents live as paupers, with no personal possessions and often no personal clothing. They are frequently dressed / undressed in the middle of a day room, bathed in large groups, toileted in hallways on potty trolleys, and generally treated with little respect for the dignity and privacy of each person. Staff have become insensitive to the dehumanising aspects of these care procedures.”[1002]

690. The basic human need to be recognised and celebrated as an individual was neglected within these large-scale care settings. Denying someone the opportunity to express themselves and explore their unique skills and interests goes with the erosion of personal identity and ultimately institutionalisation – a feature of large-scale psychopaedic and psychiatric settings.

691. In psychiatric institutions, people would live in pyjamas or dressing gowns issued to them upon arrival.[1003] Survivors were also not given their own clothes in psychopaedic institutions.[1004] Sir Robert Martin said that at Kimberley Centre near Taitoko Levin he had to share a pool of clothes and grab what he could get and never had his own underwear.[1005]

692. This stripping of individuality did not only happen with physical appearance. Ms KH, former Templeton Centre located near Ōtautahi Christchurch staff member, believes some staff members did not see the residents as people. She said that residents at Templeton were rarely called by their given name.[1006]

693. The Inquiry heard how people were transferred between psychopaedic and psychiatric institutions “in busloads and treated as a group, all assigned the same birthday once they arrived”.[1007]

Te whakahapa-ā-kareāroto, ā-hinengaro, ā-whanaketanga hoki i roto i ngā whare Kāwanatanga nui
Emotional, psychological and developmental neglect in large scale institutions

694. Across large-scale institutional settings, the Inquiry was told of survivors’ emotional, psychological and developmental needs being neglected. Aroha, care, emotional support and attention were withheld from survivors, and they were not given opportunities to grow and learn through meaningful activities and stimulation.

695. Survivor Sally Champion, who spent around three years in several hospitals from the age of 18 months to 6 years old due to polio, said “the routine of any hospital wasn’t geared towards the developmental needs of a young child, such as play, socialisation, education, love and acceptance”.[1008]

696. Former Templeton Centre staff member, Ms KH, said there were some good staff working there but that a lot “did not give a damn” and made limited attempts to engage and treat residents as individuals worthy of attention and love.[1009]

697. Margaret Priest (NZ European), whose sister Irene was admitted to the Kimberley Centre near Taitoko Levin at 6 years old said: “I do not think Irene was given any love while at Kimberley ... Most of the time, the staff I met did not see my sister as a child who needed love and care. Kimberley was just a place of people existing.”[1010]

698. Survivors of some psychiatric care settings did not feel emotionally supported to process earlier trauma and adversity they had experienced in their life, including in other State and faith-based care settings.[1011] They believe trauma and adversity probably contributed to their mental and emotional state at that time. Survivor Ms SD said she did not receive support from staff in Sunnyside to help her process grief she was experiencing alongside other challenges, and instead, “it was all just sort of brushed under the carpet.”[1012]

699. This absolute disregard for survivors’ emotional safety, and lives, was reflected in an experience the Inquiry heard from Catherine Hickey whose brother Paul “suffered prolonged and premeditated abuse [at Porirua Hospital] at the hands of the very people who were entrusted to protect him”.[1013]

“There was no value placed on his young life, and the very people who were put in that position of trust showed complete disregard for his wellbeing and safety.”[1014]

700. A 1979 letter from the psychiatric medical officer at Hawke’s Bay Psychiatric Unit to Porirua Hospital states: “I wish [Paul] better luck with his mutilation … since the only real relief I can see for him is in his death.”[1015] Paul took his own life nine months later.[JW2]

701. Emotional neglect co-occurred with other forms of neglect, including physical and medical. Survivor Alison Pascoe, who was in Carrington Hospital in Tāmaki Makaurau Auckland in 1990, said:

“If I was in pain the staff would say it was just in my mind. I once cut my arm very badly in seclusion. When [the nursing] Sister saw it, she said it was self-inflicted and they wouldn’t do anything about it. It got all infected and swelled up.”[1016]

702. In addition to emotional neglect and a lack of care and attention in the care settings, there was an “an acute lack of stimulation and purposeful activity” in daily life in institutions.[1017] Researcher Paul Milner concluded that the defining motif of a villa day room was that “on a good day nothing happened”.[1018] This was a unique and pervasive form of neglect the Inquiry heard about across psychopaedic and psychiatric institutions and hospitals.[1019]

703. Survivors and staff members shared how there were often no activities such as sports, singing or dancing, or trips outside of the institutions.[1020] Instead, some survivors undertook monotonous duties as a form of activity, such as setting up tables at mealtimes.[1021]

704. The Inquiry heard how staff interactions with residents and patients were rarely personal and based largely on getting through the regimented daily care routine.[1022] There was no time made for enjoyable activities or supporting people to develop and achieve personal goals.[1023] Further, staff recall being reprimanded if they attempted to create activity for individuals, such as through playtime.[1024]

705. The lack of activities within in-patient psychiatric units have been described by survivors as ‘intolerable’.[1025] People’s need for meaningful activity and stimulation was neglected. Samoan survivor Rachael Umaga said that at Te Whare Ahuru at Hutt Hospital:

“There was nothing to do at the unit. We just sat there all day and smoked. I felt neglected because there was nothing to do, except wait for 10 o’clock, 12 o’clock, three o’clock and five o’clock for our pills or for a cup of tea.”[1026]

706. Rachael told the Inquiry that while there was a craft room, music room and room where you could cook or bake under the supervision of a nurse, no one could do these activities because the facilities were not adequately maintained or resourced with staff to supervise: “It really felt like the staff provided us all these things to show they care but it was all just surface level and for show.”[1027]

707. The 1985 report on Tokanui Psychiatric Hospital, located south of Te Awamutu, concluded similarly: there were many residents who received minimal personal attention or effort to stimulate them and “these residents spend their days virtually ignored by staff except for foods, fluids and baths”.[1028]

708. Paul Milner, who was involved in the deinstitutionalisation of the Kimberley Centre near Taitoko Levin, said: “[Life] at Kimberley could generally be characterised by long periods of inactivity, interrupted by brief and scripted flurries of orchestrated action”.[1029] He found that more than 50 percent of residents’ time fell into the category of ‘sedentary activity’, that is, time spent “sitting, standing, staring, and snoozing”.[1030] If wandering and self-stimulation was included, approximately 80 percent of residents’ time in the Kimberley Centre was spent doing no form of purposeful activity.[1031]

709. This form of neglect could have been experienced even more acutely by individuals with high and complex support needs.[1032] Sir Robert Martin, a survivor with a learning disability, observed the following at the Kimberley Centre near Taitoko Levin:

“There was nothing to do. Some people stayed on the floor all day rocking back [and] forth. Especially people with the highest needs. There were so many of them, they were just left on the ground.”[1033]

710. Sheree Briggs, a psychopaedic training officer at Māngere Hospital in the early 1980s, shared that when she visited a ward she saw “toys stuck to the walls, out of reach of the kids. Supposedly they had been placed out of the children’s reach so that they didn’t ruin them.”[1034]

711. Survivors from Carrington Hospital in Tāmaki Makaurau Auckland and Sunnyside Hospital in Ōtautahi Christchurch recalled that residents who were teenagers or younger would wander around aimlessly because they had nothing to do.[1035] Survivors described feeling frustrated and upset because of the lack of engaging activity in psychiatric hospitals. One survivor told the Inquiry she smashed the TV at Oakley Hospital in Tāmaki Makaurau Auckland just to make things livelier:

“They made people vegetables. They’d sit you in front of the TV, you know, like a – like rows of cabbages and that kept you quiet and people would just sit watching TV. And a couple of times I smashed the TV, they never caught me, they didn’t know who did it. Just went and grabbed a handful of something and yanked. And the TV was out of order for a few days. And people started talking to each other and doing their knitting and, you know, I mean it was a little bit more lively.”[1036]

712. The experiences presented throughout this section highlight how neglect can take the form of denial of an individual’s personhood and sense of autonomy.

Te whakahapa ā-mātauranga i roto i ngā whare Kāwanatanga whaiora
Educational neglect in psychopaedic and psychiatric institutions

713. The Inquiry heard that in psychopaedic institutions such as the Kimberley Centre near Taitoko Levin and Templeton Centre near Ōtautahi Christchurch, survivors experienced serious educational neglect in the form of limited, or no access to education, and / or poor quality of education.[1037] This educational neglect contributed to an ongoing social and economic disadvantage for disabled people in these institutions.

714. Margaret, whose sister Irene Priest (NZ European) was at the Kimberley Centre for 40 years from the early 1960s, said that Irene received no education, despite the family’s request:

“It was apparent to me, though, that Irene regressed while she was at Kimberley ... From my understanding, the staff at Kimberley never made any effort to communicate with Irene. When I was older and had more involvement in Irene’s care, I asked the staff at Kimberley if they would investigate developing a specific sign language for Irene, which would allow her to point to pictures, but they did not do that.”[1038]

715. It is clear from both survivor and former staff members’ accounts that staff members assumed residents had little ability to learn.[1039] Enid Wardle, who worked at Templeton, said the training school was considered an alternative to school for children with learning disabilities. She said children were considered ‘trainable’ rather than ‘educable’ and overall, there were significant limitations in the education resources available for staff and therefore residents.[1040]

“Our teaching in the training centre focused on what the children were capable of learning, such as colours and shapes. We had to create all our learning resources using our personal knowledge. We mostly worked in classes, rather than the one-on-one, so there were no individualised education plans for the children.”[1041]

716. A 1984 review of education at the Kimberley Centre in found that only 14 of the 133 children below the age of 19 years old attended school.[1042]

717. Educational neglect was experienced in large-scale psychiatric institutions as well. Survivor Alison Pascoe shared how, during her time in Kingseat Hospital in Karaka, Tāmaki Makaurau Auckland, other children went to school but she was “deprived of an education. I was entitled to an education, and I was eligible for it, but they wouldn’t let me go.”[1043]

Te whakahapa ā-tinana i ngā whare Kāwangatanga nui
Physical neglect in large-scale institutions

718. The Inquiry heard about extreme physical neglect in large-scale disability and mental health institutions, including being denied nutritious food, hygiene needs going unmet, being left unattended and having inadequate or a complete lack of medical care and treatment. This was experienced most acutely by those with high / complex support needs, reflecting a disregard for the diverse needs of those in care and their inherent human value of people in these institutions.

719. Some survivors required staff at the institutions to assist them with bathing, but the Inquiry heard that this care was often neglected. Mr EY (Te Ati Awa, Rangitāne, Ngāi Tahu) described a distressing visit to Tokanui Psychiatric Hospital near Te Awamutu to see his brother, who had a learning disability and was a wheelchair user. Due to physical neglect of cleaning and care, Mr EY said his brother’s “whole bottom was meat. It was raw.”[1044] He told the Inquiry: “He hadn’t been cleaned, and from what I saw, it looked like he wasn’t being cleaned very often at all. The whole area he was sitting on was complete rawness.”[1045]

720. Former IHC staff member Allison Campbell said that many people coming out of the Kimberley Centre near Taitoko Levin had glue ear, hearing loss, and other hearing issues due to poor bathing practices:

“Staff members would bathe residents at the same time, and they would not change the water often enough. I heard that if patients defecated in the bath, they would just scoop it out and keep going instead of changing the bathwater. This is how so many of the patients developed ear infections which developed into hearing problems.”[1046]

721. Some survivors and staff from the Kimberley Centre recalled themselves or residents not being able to get to the bathroom and being left, sometimes to sit in their dirty clothes for long periods.[1047]

722. A 1986 report recorded that in the Kimberley Centre's Nikau Villa, it was common in the mornings to find bedridden residents who had been incontinent in the night “lying on dry drawsheets, but the lower sheet and under-blankets are saturated and offensive smelling”.[1048]

723. Some survivors described witnessing the neglect of others. Survivor Leoni McInroe was made to work in the geriatric villa while at the Lake Alice Child and Adolescent unit in Manawatū. Here she remembers seeing an elderly male patient who had “a swollen red testicle the size of a mango”.[1049] She told the Inquiry how poorly the patients were treated:

“The unit stunk of urine, faeces, decay, and old age. It was such a distressing place to be in. The sounds of groaning and muttering and despair all around, all the time. I hated being there. I was 15 years old. It was unthinkably bad.”[1050]

724. Neglect was so severe and common that diseases spread throughout some institutions, including hepatitis and intestinal infections.[1051] That people in care were allowed to remain in conditions that led to disease outbreaks is another example of widespread devaluation of disabled people and those experiencing mental distress.

725. Shigellosis, a type of intestinal infection, and hepatitis were prevalent at the Kimberley Centre near Taitoko Levin. This is acknowledged in a letter from a Kimberley medical officer to a pathologist at Palmerston North Hospital which expressed concern about these diseases.[1052] The letter noted that Kimberley Centre staff had tried their best to prevent the spread of hepatitis by contact, but that taking measures “to prevent oro-faecal spread seems a practical impossibility”.[1053] Oro-faecal is a disease route of transmission where tiny amounts of faeces from an infected person are taken in by another person through their mouth.[1054]

726. The Inquiry heard of menstruation needs being neglected. Survivor Denise Caltaux said that, because of understaffing, they were put in solitary confinement for days and was left “caked” in their own menstrual blood.[1055] Ms KH, a former staff member at Templeton in the early 1980s, said she saw a resident left in her menstrual blood.[1056] A 1986 report on the Templeton Centre, located near Ōtautahi Christchurch, noted that women in Hinau Villa were not assisted in managing their periods or using sanitary towels. While sanitary towels were available, women were instead given two pairs of large bloomers to wear which were changed irregularly during the day and no attention was given to bathing for comfort and hygiene.[1057]

727. Another form of physical neglect experienced was a lack of food or denial of individualised nutritional needs. Some survivors told the Inquiry they struggled to maintain a healthy weight. These experiences were particularly common in large-scale psychopaedic and psychiatric institutional settings.

728. Margaret, whose sister Irene Priest (NZ European) was at the Kimberley Centre, described how Irene became extremely thin, with her weight falling as low as 32 to 33kg.[1058] Catherine Hickey shared that when her mother visited her brother Paul at Porirua Hospital in the late 1970s, she found him in a “shocking state. He became like a zombie. He had always been thin but this was completely different. By the end of his life, he was emaciated.”[1059]

729. Alison Adams, whose sons Nigel and Malcolm were at the Templeton Centre located near Ōtautahi Christchurch from the late 1970s to the late 1990s, attributed Nigel’s weight loss to a lack of staff supervision at mealtimes: “The other residents were stealing all his food. I asked where the supervision was and got told Nigel needed to stick up for himself.”[1060]

730. In some institutions, a lack of access to enough food was built into the routine. A 1986 report recorded that at Templeton Hospital residents in Briar Villa would receive their evening meal at 3.30pm. This meant they would have to wait 17 hours for breakfast.[1061]

731. In other cases, the food served in institutions was unappetising or inappropriate. Ross Hamilton Clark, a blind survivor with a learning disability, said that at Kimberley Centre near Taitoko Levin they would serve lumpy porridge which he didn’t like: “I couldn’t see very well and some of the other residents warned me not to eat the porridge because there were dead flies in it.”[1062]

732. This lack of attention when food was served sometimes created dangers for residents. The Inquiry found evidence of extremely neglectful oversight in the Kimberley Centre, which resulted in three adults choking to death over a four-year period. This, and the coroner’s findings, are explored further in the Inquiry’s Kimberley Centre case study, Out of Sight, Out of Mind.

733. Caroline Arrell, a former staff member at Tokanui Psychiatric Hospital and the Kimberley Centre, shared concerns for the number of people who were fed by percutaneous endoscopic gastrostomy (PEG) at Kimberley. PEG is a feeding tube that transports food and fluid directly into the stomach. When the Kimberley Centre was closed, many people were assessed as not medically requiring the feeding tube. [1063] Caroline, whose role was to help relocate people to their new homes, said: “It was distressing to learn that many of the people who had PEGs inserted, had this due to their complex behavioural needs and absolute dislike of mealtimes.”[1064]

734. Some people in institutions were given medicines that caused extreme weight gain, leading to physical and emotional distress.[1065] Staff often failed to put in place individualised nutrition and exercise plans to prevent weight gain. Mr EY (Te Ati Awa, Rangitāne, Ngāi Tahu) whose brother was at Tokanui Psychiatric Hospital in the mid-1960s, said:

“He was squashed in [to his wheelchair]. His stomach was bulging all over. It was huge. He was about 20 stone [127 kg]. He would have been over three times the size he should have been. He couldn’t acknowledge us. He couldn’t even say anything. He was sitting there in a state of obvious anguish, in physicaI and mental pain.”[1066]

Te whakahapa ā-hauora niho, ā-hauora hoki i roto i ngā whare Kāwanatanga whaiora
Dental and medical neglect in psychopaedic and psychiatric institutions

735. The Inquiry was told about institutions’ “appalling” dental care and staff not cleaning residents’ teeth.[1067]

736. Sometimes dental neglect led to people having their teeth removed.[1068] Survivors shared about multiple instances of teeth removal, occurring both within institutions and after residents left. Margaret Priest told the Inquiry that her sister Irene had teeth problems and was scared of going to the dentist:

“The only way [Irene] could be examined was for her to be given general anesthetic. Because of the difficulty examining her teeth, the medical staff at Kimberley decided that it would be easier if all her teeth were removed.”[1069]

737. Alison Adams, whose two sons spent years at the Templeton Centre near Ōtautahi Christchurch, said it had its own dental clinic and the dental care there was good. However, the institution wanted to take out every second back tooth to make it easier for staff to clean. [1070] NZ European survivor Mr EI, who was admitted to the Kimberley Centre near Taitoko Levin in 1963 when he was 12 years old, explained that teeth were sometimes removed without injections:

“I know that kids at Kimberley had their teeth pulled out without any injections. The dentist would pull their teeth out and tell the other staff, ’Don’t worry about it, they don’t feel pain’. Of course we feel pain. Everybody feels pain. It does not matter if you are IHC or what, everybody feels pain. It makes me so angry to think about this.”[1071]

738. The Inquiry heard that wounds such as boils, ulcers and bedsores went unnoticed while in psychopaedic and psychiatric institutions.[1072] Survivors also shared that physical injuries they received as a result of abuse in care often went untreated. Survivor Alison Pascoe, who was 8 years old when she was admitted to Kingseat Hospital in Karaka in the 1950s, said:

“The staff wouldn’t do anything about my medical issues. I had broken bones from the physical abuse that I suffered at Kingseat ... I didn’t get any medical treatment for my broken bones. They let patients die because they didn’t believe them when they needed treatment.”[1073]

739. Catherine Hickey, whose brother Paul was in Porirua Hospital in the 1970s from the age of 15 to 20 years old, said her mother sometimes found Paul “cowering in a corner in the ward, with fresh bruises, black eyes, swollen lips and cuts on his body. She brought this to the hospital’s attention and nothing happened. This happened more than once.”[1074]

740. In a few cases, the failure to adequately treat injuries and illnesses led to more devastating and long-term outcomes. Sheree Briggs, a former Māngere Hospital staff member, told the Inquiry about “staff’s failure to properly treat a resident’s contractures [a tightening or shortening of muscles, tendons or joints]. This ultimately led to the amputation of his legs.”[1075]

Te whakahapa-ā-taiao tinana
Physical environment neglected

741. The environments that survivors lived in while in psychopaedic and psychiatric care were neglected themselves. Survivor Ms MQ, who was admitted to Porirua Hospital in 1982 at 19 years old, said the “most accurate description I can give of this ward is that it was the saddest place on earth”.[1076]

742. Dr Olive Webb gave evidence about the experiences of people in disability and mental health institutional settings during the Inquiry’s review period:

“You know, ‘these people’ were – this was considered to be an appropriate place for ‘these people’ and ‘these sorts of people’. They had no value and it was considered to be our social responsibility to keep people warm and well fed, end of story.”[1077]

743. However, the State failed to provide even the most basic things Dr Webb mentions, including warmth. The Inquiry was provided evidence that shows the environments of psychopaedic settings were “run down”, “poorly resourced”[1078] and “old and cold”.[1079]

744. The Inquiry heard about the “dirty and unhygienic” facilities at Māngere Hospital in 1989 from Enid Wardle, a former staff member, who said: “[You] would walk down the hallways and there would be faeces scattered on the floor.”[1080] Ms KH, said that there were some dormitories at the Templeton Centre near Ōtautahi Christchurch that never seemed to receive sunlight and were always dark.[1081] She explained the newer villas were purpose-built and had a pleasant atmosphere, but the majority of villas were barren, with wooden or linoleum floors and no curtains. She said it was always freezing, and the male villa smelt strongly of stale urine.[1082]

Te tūkinotanga ā-hauora i ngā whare Kāwanatanga nui
Medical abuse in large-scale institutions

745. People in medicalised disability and mental health institutional settings were abused by staff who had access to resources intended to deliver treatment, such as equipment and medication. Such tools were used on extremely harmful, degrading and dehumanising ways.[1083]

746. Like other forms of abuse, medical abuse could intersect with, and be compounded by, forms of discrimination, including racism. Samoan survivor Leota Scanlon shared that although he did not know what racism was at the time, he has been able to identify differential treatment in his memories of Lake Alice Child and Adolescent Unit in Manawatū:

“Looking back on my time at Lake Alice, it was clear that Polynesian and Māori kids were treated worse than the Pālagi kids because we were getting more injections and electric shocks than the Pālagi kids. There were rules for them and different rules for us.”[1084]

Ngā rautaki kaupare hei aupēhi i ngā kainoho
Aversion techniques to control residents

747. Aversion techniques were used in large-scale disability and mental health institutions as a way for staff to assert control over children, young people and adults in care. This report refers to these as aversive ‘techniques’, not therapy, as they often involved the misuse of medical equipment, such as electro-convulsive therapy (also known as ‘ECT’) machines and known painful injections, without usual administration protocols being followed. Drugs that produced nausea and induced sleep were also used to deliver aversion techniques.

748. For example, when given according to protocol, electro-convulsive therapy involves the induction of a seizure (convulsion) through the application of an electrical stimulus (current) to the brain. A specified number of treatments are administered weekly over a specified period.[1085] Prior to the mid-1950s, electro-convulsive therapy was often delivered without anaesthetic and muscle relaxant (referred to as unmodified ‘ECT’).[1086] However, by the 1960s, this had changed, and the standard practice was for electro-convulsive therapy to be administered with general anaesthesia and muscle relaxants (referred to as modified ‘ECT’).[1087] By the 1970s, it was no longer considered appropriate to administer unmodified electro-convulsive therapy.[1088]

749. In the 1970s, electro-convulsive therapy was primarily used to treat those with severe depression (now known as ‘major depression’) as well as people with mania and schizophrenia.[1089] Its primary purpose is to rapidly relieve unwanted symptoms of a mental health condition.[1090]

750. As detailed in Beautiful Children, the Inquiry’s interim report into the Lake Alice Child and Adolescent Unit, electro-convulsive therapy machines were used to deliver electric shocks – often without anaesthetic – as punishment. This was experienced by survivors and staff from other psychiatric institutions as well, such as Carrington Hospital in Tāmaki Makaurau Auckland and Porirua Hospital.[1091]

751. Survivor Keith Wiffin received an electroencephalogram, also known as an ‘EEG’ at Porirua Hospital in 1970. After this he was diagnosed with a form of epilepsy and prescribed a sedative and an anti-convulsant drug.[1092] Keith believed the electroencephalogram test was used as a convenient excuse to get him on this medication, and stated that this diagnosis was never supported by medical evidence or any of his subsequent doctors.[1093]

752. Injections of paraldehyde were primarily used in psychiatric institutions, but in some instances, were also used in social welfare institutions. The Inquiry heard this happened in response to unwanted behaviours such as attempting to run away. [1094] It is important to note that running away can be a trauma response that could have been explained by survivors’ experiences in these settings.

753. There are examples of equipment available in a medicalised environment being misused to punish and even torture individuals. The Inquiry’s investigation into the Lake Alice Child and Adolescent Unit found that the use of electric shocks and paraldehyde to punish met the definition of torture as outlined by the Solicitor-General.[1095]

754. Aversion techniques at Māngere Hospital included the delivery of electric shocks through belts and helmets developed by staff, snapping ammonia capsules under a person’s nose, giving residents cold showers and spraying water on their faces.[1096]

755. While aversive techniques were still being promoted in Aotearoa New Zealand in the 1980s, they were considered outdated and poor practice in the UK because of their serious and traumatising side effects.[1097]

Ngā ritenga panoni hemahematanga
Conversion techniques

756. Other types of medical equipment, as well as drugs that produced nausea and inhibited sleep, were used to deliver aversion and conversion techniques. The punitive approach of conversion practices, whereby individuals in psychiatric settings had to deny their sexuality or be subjected to electric shocks under the guise of ‘treatment’, reflected the discrimination and denigration of homosexuality in wider society.

757. For example, an appendix to the 1962 Kingseat Hospital in Karaka annual report states that a unit was organised at the hospital to conduct behaviour therapy, where three homosexuals had been treated.[1098] A room was “painted black with all light sources blocked” and “when the patient became anxious a tape was played decrying the activities for which they sought treatment”.[1099] The second phase of the ‘treatment’ involved “prolonged wakefulness” through the administration of methedrine – another term for methamphetamine – and apomorphine, delivered every four hours.[1100]

“With the appearance of guilt and depression the tape and the attitudes of the Nurses and Medical Staff changed from a critical derogatory one to a congratulatory and optimistic approach. At this time the patients felt that they were able to handle their problem.”[1101]

758. The report noted that one of these patients was subjected to slightly different conversion techniques:

“The last homosexual treated was under treatment for only 12 hours. Here, the aversion was not produced by electrical stimulation or nausea as had been done in the other cases, but by a feeling of depression and hopelessness produced by personal criticisms while under the influence of Lysergic Acid. Various masculine members of the staff adopted a critical, disparaging role, while some feminine volunteers from the staff adopted an optimistic encouraging role. With the distortion of the patient’s time sense, he felt the treatment had extended over a period of perhaps a week.”[1102]

759. The Inquiry has also heard from Michael Ferriss, director of the New Zealand chapter of the Citizens Commission on Human Rights. He said that in 1992, a Citizens Commission on Human Rights volunteer interviewed the clinical supervisor at Kingseat Hospital who discussed treatments conducted in the 1960s, including behaviour modification in the form of electric shocks to homosexual patients’ genitals.[1103] This was using a modified machine otherwise used to try to treat bed-wetting.[1104] The clinical advisor explained that while the patient had to give consent for the treatment, he did not believe individuals were prepared for how intense this treatment would be.[1105] The Inquiry has not received any other witness evidence, or any other evidence, of this kind of treatment at Kingseat Hospital. The Inquiry is unable to confirm the accuracy of this evidence.

760. The Inquiry has seen some evidence that aversion techniques at Kingseat Hospital in Karaka were used with both abusers of sexual abuse against children and homosexual patients, without making a distinction between these groups.[1106] This highlights the harmful association at the time between homosexuality and perversion.[1107]

761. NZ European survivor Peter Saffill, who also spent time at Tokanui Psychiatric Hospital located south of Te Awamutu, shared the story of his friend who he described affectionately as a “queen”, who was subjected to multiple instances of electric shocks. Peter described getting hold of their friend’s medical files and reading the following:

“And in the file, it said … question, ‘Are you still a homosexual? Are you a homosexual’? ‘Yes’. ‘Shock treatment’. Question, ‘Are you a homosexual’? ‘Yes’. ‘Shock treatment’. This went on for quite a while. So, ‘Are you a homosexual’? and [my friend] said, ’I don’t know’. And I cried and I cried, and I cried. [My friend] didn’t say, ‘No’, he said, ‘I don't know’, and that was the first sign of him not being able to hold out anymore.”[1108]

762. Peter is also gay, but he did not receive any ECT. He did see the debilitating impact it had on his friend through the attempt to erase part of his identity: “And I sat there and watched my friend become a vegetable, couldn’t talk to me, couldn’t play, couldn’t do anything.”[1109]

763. Survivor Mr Invictus[1110] described the experiences of an acquaintance who was taken to Carrington and later took his own life. Mr Invictus said that staff “put him in a room, probably with a couple of attendants, and they showed him pornographic films between males or something or other. When [he] would get some pleasure out of looking at [the film], [the staff would] give [him] some kind of shock treatment.”[1111]

764. New Zealand Māori survivor Joshy Fitzgerald (Te Arawa), who was at Tokanui Psychiatric Hospital as teenager, described how staff knew he was gay and tried to “shock the gayness” out of him: “And then while I was there, I … had three lots of electric shock treatment and I was about 15”.[1112] Joshy said no one talked to him about being diagnosed with anything, but that once he mentioned he was gay “everything changed”:

“That’s when they did the electric shock treatment. I wasn’t diagnosed with anything that I can remember… I received the electric shocks because I was gay.

I remember when I was walking to get the first shock done and asked, ‘Where are you taking me’? The male staff member said, ‘We’ve got to get this gay out of you’. I said, ‘Well, it’s not something that I choose to be’. There was this talk with me, but it was really short and that’s when I knew I was having it for being gay.

I just had the three sessions of electric shock treatment and then nothing was ever said. I had no choice in whether to receive the electric shocks… I don’t remember a lot after the ECTs. It’s like it wiped my memory. The three or four months before the ECT, I don’t have any memory.”[1113]

765. These examples demonstrate how medical conversion therapy medicalised a non-medical issue and denied survivors their agency.

Ngā rongoā me ngā pūmatū hei aupēhi, hei mahere hoki i ngā kainoho
Medications and chemicals to control and restrain residents

766. Survivors also experienced chemical restraint in psychiatric settings, which was often used instead of providing appropriate treatment.[1114] NZ European Mr SA, a survivor with a learning disability, described being “drugged up” on Largactil (a sedating medication) at Tokanui Psychiatric Hospital.[1115] Survivor Alison Pascoe (NZ European) was also injected with Largactil while at Kingseat Hospital, which she described as “chemical straitjacket therapy”.[1116]

767. David Newman described his brother’s experiences of overmedication and polypharmacy (taking a large amount of medication) at the Kimberley Centre near Taitoko Levin, Templeton and Brackenridge Estate (located on the former Templeton Centre site) near Ōtautahi Christchurch and Hillmorton Hospital in Ōtautahi Christchurch.[1117] David said his brother “was essentially managed by sedation as a means of behavioural control”.[1118]

768. Gary Hobson, who has attention deficit hyperactivity disorder and spent seven months as a forensic patient at Oakley Hospital in Tāmaki Makaurau Auckland, shared how he felt after being overmedicalised and receiving electroconvulsive therapy: ’After a few days, I was put back in the room with every other zombie. I didn't want to be like everyone else, but I acted and looked like them.”[1119]

769. Sharon Brandford, who has worked to support people with learning disabilities for more than 35 years, explained that there was diagnostic overshadowing present in disability care settings. This is where a health or behavioural presentation is assumed to be because of a person’s disability.[1120] She had seen “several women in their 40’s treated with psychotropic medication for agitation and distress when their issue was menopause”.[1121]

I whakahēngia ngā mōtika whakaputa uri o ngā kainoho
Residents were denied their reproductive rights

770. The Inquiry has reviewed information, including material that has been provided by the Citizens Commission on Human Rights New Zealand, regarding people in psychiatric settings being administered treatment without their informed consent,[1122] being forced to receive injections,[1123] and not being informed of potential side effects of contraceptives.[1124] Sometimes these failures to consult were in contravention of hospital policies that encouraged consent to be sought from residents.

771. A 1980s Cherry Farm (located near Ōtepoti Dunedin) clinical management manual for so-called ‘intellectually handicapped’ residents states that decisions around contraception for female patients should be “taken by medical staff in consultation with nursing staff and, where possible, the resident herself”.[1125]

772. The Inquiry also heard of parents who were not consulted on contraceptive practices. This is evident in a 1977 complaint, provided by Citizens Commission on Human Rights New Zealand, from parents whose daughter was administered contraception at Porirua Hospital without any parental consultation when she was 12-years-old.[1126] The parents asked social welfare why she was being administered the contraceptive injection (Depo-Provera) and were informed that the hospital had the authority to administer it.[1127] In later years, Porirua Hospital recognised some of the problematic policies around the administration of contraception and sought to change them.[1128]

773. Māori survivor Walton James Ngatai-Mathieson (Ngāti Porou), who had been in Lake Alice Child and Adolescent Unit in Manawatū, told the Inquiry that staff members gave drugs to male patients that left them impotent, and that a staff member gave him pills that chemically castrated him, saying:

“I was given a ‘blue pill’ when I was older at Lake Alice. I understood this was to make sure I could not get anyone pregnant. I called it the ‘kill cocker’. This belief was confirmed by what other patients also told me.”[1129]

774. Institutional evidence revealed sterilisation referrals and sterilisations occurred in inappropriate circumstances and circumstances where consent was unclear.

775. In a 1988 letter from a medical officer to a consultant obstetrician, the medical officer noted that the family of a Tokanui Psychiatric Hospital patient located south of Te Awamutu wished for her to have a tubal ligation. The letter said that the patient did not want more children “but would prefer Depo-Provera as she says it would be less painful”.[1130] Despite this preference the letter went on to request that consultant obstetrician consider tubal ligation, noting that the patient “might have a lucid moment and agree”.[1131]

776. A 1978 affidavit by a patient that resided at Kingseat Hospital in Karaka also outlines a sterilisation procedure occurring in inappropriate circumstances. The patient shared that during her admission to Kingseat Hospital in 1974, she discovered she “had had a tubal ligation and became very upset”. She was informed she had agreed to this operation when she was in a depressed state.[1132]

777. In a 2004 report provided to the Minister of Health, a total of 24 cases were identified of women with learning disabilities who received hysterectomies from 1997 to 2000. The report noted that of these cases, 16 of the patients’ received hysterectomies to manage excessive and frequent menstruation, the average age of these patients was 15 years old. The patient’s ability to participate in decision/consent processes was also noted – in one case, a patient had limited to reasonable ability, in another case, a patient had limited ability, and in 12 cases, patients were unable to participate in decision/consent processes.[1133] Earlier statistics, reported in an unpublished paper by disability researcher Sue Gates, found that from 1991 to 1994, 169 New Zealanders with a learning disability were sterilised, 40 of whom were under 15 years old.[1134]

778. Failures to discuss contraception with patients or to obtain their consent illustrate pervasive disregard for the agency of the individuals in disability and mental health settings.[1135] Roderick Wills, a staff member who worked as a social worker at Māngere Hospital from 1989 to 1993, said the “notion of consent was not part of the culture of care”.[1136]

779. The Inquiry was told of people being forced to have abortions while living at disability and mental health institutions and that there was a lack of informed consent around this process. Sometimes survivors had become pregnant as a result of sexual abuse within institutions.[1137]

780. Survivors said they did not consent to abortion procedures and often only realised they had received an abortion after the procedure had occurred.[1138] Survivor Ms WC, who was admitted to Oakley Hospital at 15 years old and was there for four years, shared that she watched her pregnant friend being taken into a room:

“She was screaming. Once they had finished, she wasn’t pregnant anymore. She later told me that she was aborted ... I don’t know why they did that to her, or to any of us. I don’t think they liked disgraced, unmarried, pregnant women. They treated me badly, too – I was just a slut to them. It didn’t matter what had caused it, or that we had been abused. They were so degrading to women.”[1139]

781. Survivor Ms GI told the Inquiry that her sister, who was in a psychiatric institution, woke up to find that she was undergoing an abortion:

“She said that she did not want the abortion, but one night she had woken up and they were operating on her to abort the baby. I am certain that this put her into a deeper depression.”[1140]

Kāore he whakamōhiotanga whakaaetanga i roto i ngā mahi rangahau me ngā whakamahutanga
Lack of informed consent in research trials and treatments

782. Sheree Briggs, a former Māngere Hospital staff member, told the Inquiry that research trials were conducted at the hospital. Sheree was not aware of consent being given by the people receiving the medication, or their parents.[1141] The research was for anti-psychotic drugs and they were trialled on children as young as 5 years old.[1142]

783. Dr Olive Webb told the Inquiry she was aware of research being conducted at Māngere Hospital and the Templeton Centre near Ōtautahi Christchurch, where prescribed medications were being manipulated.[1143] She said that when the researcher was at a meeting with psychologists, he chuckled and said: "It's great because the retards are one step higher than rats”.[1144]

784. Dr Ken Bragan, a psychiatrist who worked at Cherry Farm in the late 1960s, said:

“I think there was a general attitude among some psychiatrists, during the mid-20 century, of wanting to give new treatments a go … If you look at it objectively, I think these psychiatrists were pursuing these treatments for their own interests rather than that of their patients.”[1145]

785. The Inquiry received evidence of psychiatrists in Aotearoa New Zealand using LSD treatment “despite this method being on the fringes of psychiatry even in the 1970s”.[1146] The Inquiry also heard there could have been unconsented LSD trials at Cherry Farm and Ngawhatu Psychiatric Hospital.[1147]

786. In 1979, George Gair, the Minister of Health, advised that approval for the use of psilocybin (an hallucinogen) had been overlooked and the requirement of the Misuse of Drugs Act 1975 had not been met.[1148] Correspondence notes that the use of the drug on two children had been discussed with their parents and the technical breach remedied with retrospective approval from the Minister of Health.[1149]

787. Dr John Werry, a child psychiatrist, explained that when he moved back to Aotearoa New Zealand from the United States in the early 1970s, he was horrified to find that lobotomies were still being performed here, given that “the practice of lobotomy was almost unknown in the United States by that time”.[1150] He said:

“I found … that psychosurgeries [also known as neuro-lobotomies] were still being performed on patients at Oakley Hospital, then under Dr Pat Savage. Dr Savage would have been the most senior psychiatrist in New Zealand at that time. He was very old-fashioned. He believed in hospital care for everybody and in locking people away in mental hospitals … Patients were supposed to have an independent psychiatric review before such treatment, so I was surprised to learn that Dr Savage used to send patients for surgery with minimal checks.”[1151]

788. NZ European survivor Ms LU, reflected on the lack of informed consent surrounding her neurosurgery – also known as a lobotomy – that took place in 1974 at Wellington Hospital when she was 29 years old:

“I can’t remember Dr Leeks or Dr Fama explaining to me what the surgery entailed, what it was for or any possible complications … If, at the time, they had asked for my consent to do the operation, I would have said no. How dare they muck around on my brain. Even though I was a frightened little girl, I still would have said no. I was under lots of medication at the time. I was like a zombie so I’m not sure if my parents were involved in the decision to have the surgery.”[1152]

789. Ms LU said she continues to experience negative mental and emotional impacts because of this surgery.[1153]

Te tūponotanga o te pāngia o ngā purapura ora e ngā pokanga hinengaro ā-hiko
Survivors could have experienced electrical lobotomies

790. A paper published in the 1958 New Zealand Medical Journal described the treatment of 25 women over the previous eight years in Aotearoa New Zealand who were “given ECT beyond the stage of gross confusion, to a stage where there is temporary dementia, with complete disintegration and loss of personality”.[1154] The treatments were given once daily. The author stated:

“After a week or more, mental confusion and imperception occur, so that the patient does not recognise objects, persons and places. There is complete poverty of imagination, so that while at first some effort may be made to get out of bed to the toilet, the patient eventually becomes incontinent of urine and faeces unless regularly toileted. Eventually complete aphasia and agnosia occur, and finally there is a breaking up of the personality organisation. It is important at this stage that the treatment be continued until there is complete loss of personality. The patient may show gross regression until she curls up into the antenatal position.”[1155]

791. Aphasia refers to a disorder that results from damage to portions of the brain that are responsible for language, and therefore impairs one’s ability to express and understand language as well as their ability to read and write.[1156] Agnosia is a neurological disorder characterised by an inability to recognise and identify things such as objects or people’s faces and voices.[1157] Both of these ‘disorders’ typically result from damage to areas of the brain from strokes, traumatic brain injuries, or other neurological conditions.

792. No survivors shared their experiences of receiving this procedure with the Inquiry, and there is no other evidence of it, although the Citizens Commission on Human Rights New Zealand identified 10 survivors when they investigated this ‘treatment’ in 1998.[1158] That statement detailed how survivors “expressed severe memory loss and other mentally and physically debilitating conditions as a result of the ‘treatment’”.[1159]

Te whakataratahitanga hei whakahaere i ngā kainoho
Solitary confinement to manage residents

793. Solitary confinement, sometimes referred to as ‘seclusion’, was used as punishment, behavioural ‘management’ and even convenience in some large-scale institutional settings. Solitary confinement was used as part of the daily routine in some of these institutions and the Inquiry heard from survivors that its use was psychologically and physically abusive. Survivors’ experiences in these often-barren spaces were characterised by a lack of access to toilets, showers and water and being isolated for a long time.

794. Survivors shared that they were ‘locked up’ all the time and treated like prisoners.[1160] Survivors were commonly put in solitary confinement as punishment for running away.[1161] Survivor Brian Moody told the Inquiry he was secluded as retaliation for a complaint he made against staff.[1162]

795. Margaret is aware from her sister Irene Priest’s (NZ European) files, that Irene was placed in solitary confinement at the Kimberley Centre near Taitoko Levin as punishment for her behaviour.[1163] The records show that she was placed in solitary confinement on at least 18 occasions from June to August in 1990.[1164] Matthew Whiting, a Māori survivor with cerebral palsy, described being placed in a room at Pukeora Hospital and being unable to leave. He explained that he witnessed similar punishments given to other residents.[1165]

796. ‘Time out boxes’ were used as part of a ‘behaviour programme’, based on aversion technique principles, at Māngere Hospital. Sheree Briggs, former Māngere Hospital staff member, explained that this aversion technique characterised by solitary confinement was “typically for response to aggressive behaviour, sometimes self-injurious behaviour and a person when they engaged in this specific identified behaviour were restrained and taken down to the time out box and placed in there until they were calm”.[1166]

797. These small, wooden, lockable boxes which existed in multiple rooms at Māngere Hospital only allowed for minimal movement once someone was put in them. Sheree Briggs explained that “most of the time [people put into the box] would stand and smash against the wall or bang their heads against the walls and scream”, and that there was no set amount of time someone would remain in there. One young boy was in there for over an hour for biting.[1167]

798. While solitary confinement was sometimes used to try to manage perceived challenging behaviour, it was also sometimes embedded into the standard practices of the institution.[1168] Samoan, Gypsy survivor Antony Dalton-Wilson told the Inquiry that new arrivals to Māngere Hospital were placed in solitary confinement without explanation.[1169]

799. In some disability settings, solitary confinement was used for the convenience of staff. For example, in a letter to the chief nurse of the Canterbury Hospital Board, the acting head of the nursing studies department at Christchurch Polytechnic described how solitary confinement was being “used for illegal lengthy periods so staff can have morning tea without interruption”.[1170]

800. The Inquiry also heard of degrading abuse experienced by survivors while in solitary confinement. NZ European survivor Steven Storer, who was in Oakley Hospital in Tāmaki Makaurau Auckland in the mid-1970s, shared that he would be left in a padded room with no toilet and “you would just soil yourself then at the end get hosed down”.[1171]

801. At the Inquiry’s State Institutional Response Hearing, the Ministry of Health and Whaikaha acknowledged the inappropriate use of seclusion, which is referred to in this report as solitary confinement, as well as restraints, that took place in psychopaedic and psychiatric settings.[1172]

Read the next part of Chapter 4 here

Footnotes

[982] Witness statement of Roderick Wills (5 August 2022, page 9); Helen Porter (26 August 2022, page 9) and Sunny Webster (18 December 2021, page 9).