363.    Complaints were made to the Department of Social Welfare from boys referred from Holdsworth and by Lake Alice school staff. Complaints were also made to the Department of Education.

Ngā amuamu a ngā tama i whakawhitia atu i Holdsworth - Complaints of boys referred from Holdsworth

364.    Complaints were raised with the Department of Social Welfare about the unit from as early as 1973 and came from boys taken to Lake Alice from Holdsworth. The Department of Social Welfare’s response to these and subsequent complaints showed a deferential attitude towards clinical decisions at the unit. As a result, complaints were generally not believed or acted on. The complaints process at the unit is discussed further in chapter 2.3.

365.    We next discuss the earliest recorded complaint, from Mr EG, followed by complaints from Mr EK and other boys from Holdsworth. We then discuss the roles of Holdsworth staff, social workers and the Department of Social Welfare

Earliest complaint - Mr EG

366.    The earliest recorded complaint relates to Mr EG. He was admitted to Lake Alice in November 1972 after absconding from Holdsworth and was discharged a month later.^[803] He was given “three treatments of ECT” while at the unit.^[804] Mr EG told his social worker, Mr Sumich, he had “been given ‘shock treatment’ as a punishment” while at Lake Alice.^[805] He complained that he had received this as “unmodified shock treatment” and said the hospital was “not meant to give the treatment in an unmodified form”.^[806] On 19 January 1973, Mr Sumich sent a letter to Mr John Hills, the Department of Social Welfare’s Christchurch director, describing Mr EG’s complaint and recommending a report be obtained from Lake Alice on Mr EG’s treatment.^[807] 

367.    The social worker said Mr EG’s behaviour had reportedly improved after the treatment and stated that he did not consider it likely that hospital authorities would use shock treatment as punishment, but,

“unfortunately [Mr EG] believes this to be so and has spread the belief to other inmates at Holdsworth School … I was informed by another inmate [survivor], that if you abscond from Holdsworth, you are punished by being given shock treatment at Lake Alice Hospital”.^[808] 

368.    In response, Mr Hills wrote to Mr Powierza, the principal at Holdsworth, on 25 January 1973, copying in the Director-General of Social Welfare, saying that although “there was always some risk in accepting unconfirmed statements of boys”, there was “some concern” with a boy making a statement regarding his treatment at Lake Alice.^[809] Mr Hills’ concern, however, was around the danger that such “distorted reports” might spread and “harm the professional reputation of staff who were working perhaps under difficult conditions, with difficult people to care for”.^[810] Rather than asking for a report about Mr EG’s treatment from Lake Alice, as Mr Sumich had recommended, or otherwise investigating the complaint, Mr Hills suggested Mr Powierza have a discussion with the medical superintendent of Lake Alice, “so that he may be fully aware of the type of patient he has”.^[811] Mr Powierza replied to Mr Hills on 26 February 1973, copying in the acting Director-General of Social Welfare.

“I consider that it would be imprudent of me to suggest to the Medical Superintendent of Lake Alice that he is not aware of the sorts of patients that he has. I will, at some appropriate time, unofficially, make comment to Dr Leeks, the Consulting Psychiatrist, but this is all that I am prepared to do.”^[812] 

69.    Further, Mr Powierza said Holdsworth had previously sent six children to Lake Alice, and others as outpatients to visit psychiatric nurses, and “none of [the] children have any exaggerated fears of going to Lake Alice”.^[813] 

“The connotation that shock treatment is used as a punishment may in fact be real in its consequences; it may even be the intention of the medical specialists. Be that as it may, the results so far have been most rewarding and, if we are to use psychiatric facilities, then surely, we must accept the psychiatrists’ modus apparatus.”^[814] 

370.    Mr Powierza appeared unconcerned by the possibility that shock treatment was being given as punishment as he was generally pleased with the result this method was producing.^[815] In a note on Mr EG’s file from 22 November 1972, Mr Powierza noted that a report from Lake Alice indicated Mr EG’s “anti-social behaviour, stealing, pathological lying, and aggressiveness are such that on the first day he transgressed the rules and was given E.C.T.”.^[816] 

Mr EK

371.    Mr Powierza’s response to the Department of Social Welfare is not only surprising in its lack of concern about the methods being used at the unit, but also in its inaccurate account of the lack of fear of Lake Alice among other boys who had been admitted there. Only days before Mr Powierza received the letter from Mr Hills, he recorded an incident that occurred at Holdsworth involving another boy, Mr EK,^[817] who had been previously admitted to Lake Alice for several weeks in late 1972.^[818] 

372.    On 24 January 1973, Mr Powierza made a file note about an incident at Holdsworth the previous evening. Mr EK and two other boys had been caught misbehaving. Mr Powierza said Mr EK had become “hysterical” and begged the housemaster not to send him back. He had become so distraught the housemaster eventually called Mr Powierza. Immediately on seeing Mr Powierza,

“[Mr EK] threw himself at me, pleading that he not be sent back to Lake Alice. After calming him I told him that if he continued with his persistent aggressive behaviour with the other children, or if he did behave in an inappropriate manner … we would have to refer the incident to Dr Leeks, who would make the decision.”^[819]

373.    The next day, Mr Powierza recorded that Mr Hunt had spoken to Mr EK and he was still “distraught in his fear of being returned to Lake Alice”.^[820]Although Mr EK was not returned to Lake Alice, Holdsworth staff continued to threaten him with re-admission to the unit.^[821]

374.    Records from Mr EK’s consultation with Department of Social Welfare physician, Dr Lovell Frost, in February 1974 show Mr EK said he had been at Lake Alice twice and given electric shocks three times as a “punitive measure”.^[822]Dr Frost wrote a question mark next to EK’s claim of having received shock treatment. This inquiry found no evidence of any follow-up action.

375.    In 1977, a Holdsworth teacher described Mr EK’s behaviour as “disturbed for a long time” afterwards:

“All the boys in my classroom who had received ECT became worse after they had received it. They all became violent. The ECT seemed to have changed the personality for the worse in all the boys I have seen after ECT. Some of the boys told me that they were held down and then given ECT. They told me that this was an extremely painful experience.”^[823]

Ngā wheako o ngā purapura ora nō Holdsworth - Experience of survivors from Holdsworth

376.    On 17 March 1973, a social worker visited a boy from Holdsworth, Mr DS, who had been admitted to Lake Alice. The social worker recorded in a file note a week later that Mr Hunt, the charge nurse, had said there was a possibility Mr DS would receive “E.C.T. treatment” because he “tends to continue to do things which are not acceptable a short time after being warned”.^[824]

377.    On 3 August 1973, an acting housemaster of Holdsworth took Mr Wickliffe to Lake Alice from Holdsworth for a brief stay to receive ECT treatment. The file note of 9 August 1973 from the housemaster records that Dr Leeks had warned Mr Wickliffe “should he continue to misbehave at Holdsworth, more treatment would follow”.^[825]Mr Wickliffe recalls that he was taken to Lake Alice from time to time for shock treatment and it was used as a “scare tactic and punishment”.^[826]

378.    In 1973, Mr Watson, a Holdsworth housemaster, recalled becoming increasingly concerned at the reasons boys were being sent to Lake Alice. Most boys were referred by Mr John Drake, who became acting principal at Holdsworth after Mr Powierza resigned, for persistent absconding or aggressive behaviour.^[827]Mr Watson considered the school could manage this sort of misbehaviour. He expressed concern to Mr Drake that he was “sending those boys to a psychiatric hospital as punishment for misbehaviour at Holdsworth”.^[828]Mr Drake never acted on Mr Watson’s concerns.

379.    At that time, Mr Watson said that he thought about raising concerns several times with the Department of Social Welfare head office, but such complaints needed to be in writing and go through Mr Drake as the acting principal and he would intercept them.^[829]

380.    Mr Watson, who was also studying psychology at Massey University at the time, said he became increasingly concerned about what was happening at Lake Alice. One day in 1973, Mr Watson said he drove to the hospital to check on the Holdsworth boys he was responsible for. He says he spoke with five boys that day, including Mr Marks who recalled the conversation with Mr Watson,^[830]and asked them how they were doing.

“They appeared to be really scared and told me they had been administered electro-convulsive therapy (ECT) to their heads and electric shocks to their legs, without first receiving anaesthetic or muscle relaxant. They said they had been given these electric shocks as a form of punishment by Dr Leeks.”^[831]

381.    Mr Watson said he believed what the boys were telling him and contacted Dr Leeks.^[832]He said Dr Leeks denied ECT had been given as punishment and said the boys were lying.^[833]He recalled that Dr Leeks said something to him along the lines of “I’m the psychiatrist here, you’re just a psychologist in training”.^[834]Mr Watson said he also later contacted the Department’s head office about complaints of mistreatment at Lake Alice.^[835]  He did not recall the Department undertaking any investigation into his concerns about Lake Alice.^[836]

382.    Mr Marks repeated his complaint in 1976 to child psychiatrist Dr Jim Methven. He told Dr Methven he had ECT twice without injections, and that “all the boys were scared of [the electric shocks]”.^[837]

Te wāhi ki ngā kaimahi o Holdsworth i ngā whakawhitinga atu - The role of Holdsworth staff in referrals

383.    Mr Drake played a key role in the referral of boys from Holdsworth to Lake Alice. Several Holdsworth survivors who were sent to Lake Alice by Mr Drake, including Mr EK, Mr Marks and Mr Wickliffe, also told us they were repeatedly sexually and physically abused by Mr Drake while at Holdsworth.^[838] Mr Wickliffe said deputy principal Duncan McDonald and two other staff members at Holdsworth also sexually assaulted him.^[839] This group of survivors said they told other staff about the abuse at the time, but were either disbelieved or ignored. Mr Wickliffe said he told everyone who would listen but was told he was lying.^[840] The abuse at Holdsworth created a vicious circle. Boys would often react to the abuse by absconding or ‘misbehaving’, and their abusers would respond by sending them to Lake Alice for ‘behavioural reasons’.^[841] Mr EK said:

“Drake was a paedophile. He did it to me and I complained. I wasn’t listened to. I tried to kill myself … and because of that, that’s how I ended up in Lake Alice. You see what happens? They violate you; you complain, you get punished further – and nothing happens to the perpetrator. Silence is golden.”^[842]

Tā ngā tauwhiro me te Tari Toko i Te Ora i mōhio ai - What social workers and the Department of Social Welfare knew

384.    Holdsworth volunteer, Jill Winsor, and several former Department of Social Welfare employees, including social workers and teachers, gave evidence to the inquiry consistent with the accounts of survivors from Holdsworth who were sent to Lake Alice. Some social workers said the boys told them they were getting ECT as punishment and were fearful of ECT. They also said they themselves had heard social workers threaten to send boys to Lake Alice if they misbehaved.^[843]

385.    Social worker, Alan Cruise-Johnston, said he spoke to Lake Alice staff after boys told him about the use of ECT as punishment and was assured this was not the case.^[844] Mr Cruise-Johnston told us the culture of the Department at the time was “not to inquire further”.^[845] “I wanted to accept it, unfortunately, as I couldn’t bring myself to believe that such a thing could be happening.”^[846]

386.    Field social worker Dal Janes said that if an individual had complained to him about mistreatment at Lake Alice, he would have made a complaint to the hospital staff and the Department’s Whanganui director, Eric Medcalf. However, he believed Mr Medcalf would have “brushed off the complaint”.^[847] Mr Janes considered that Mr Medcalf would have “liked to stick to the rules and preferred to keep the affairs of [the Department] and the [unit] separate”.^[848]  Mr Janes also recalls another male staff member at the Department “blowing the whistle on Dr Leeks and getting heavily reprimanded”.^[849] 

387.    This is consistent with the response that a youth aid officer, Tony Sutherland, got from Mr Medcalf.^[850] Mr Sutherland also recalled raising concerns about referrals from Holdsworth to Lake Alice with Ray Wallace, second in charge of the Child Welfare Department in Whanganui. Mr Wallace shut him down and wouldn’t allow the matter to be discussed at a Department meeting.^[851] Mr Wallace told Mr Sutherland it was a matter for Holdsworth and not part of the agenda.^[852] This shocked Mr Sutherland. He believes Mr Wallace had knowledge of the basis for referrals from Holdsworth to Lake Alice before Mr Sutherland raised the matter and that the Department in Whanganui was “motivated to keep the district squeaky clean”.^[853]

Ngā mānukanuka o ngā kaimahi o te kura o Lake Alice - Concerns from Lake Alice school staff

388.    We received statements from six former Lake Alice school staff (two relieving principals, a principal and three teachers). These staff members were employed for various periods between 1973 and 1978. Many of them recalled hearing students and/or nursing staff talking about the use of electric shocks as punishment. One teacher who was at the Lake Alice school for a short time in 1973, said he “understood the [electric] shocks to be a disciplinary measure” and thinks one of the nurses may have told him this.^[854] He considers the unit was using electric shocks as a form of corporal punishment in a similar way strapping was used in primary schools and caning in secondary schools during the 1970s.^[855] However, he felt it “wasn’t [his] place as a teacher to question the treatments that were being administered by medical professionals”.^[856]

389.    The Lake Alice school’s first teacher was appointed in May 1973. She told us she witnessed how fearful students were of electric shocks,^[857] or the “zapper” as they called it, and saw nurses threaten its use.

“I’m pretty sure the ‘zapper’ was always talked about in terms of punishment because I remember the guards making threats to the kids in the classroom, such as watch yourself or you’ll get the zapper. There may have been therapeutic reasons for it, but the kids didn’t seem to see it that way. I guess I didn’t see it as therapeutic either because it always seemed to be a threat for misbehaviour…there was a lot of fear at the same time. They were scared of the ECT. With respect to the fear the students had that I witnessed at Lake Alice, I have never encountered this fear in any other educational facility I have worked in”.^[858]

390.    She also said: “My reaction to ECT given to kids in Lake Alice was that it was clearly wrong”, but “[e]ven if I had wanted to raise concerns about the treatment of kids, there wasn’t anybody I knew to talk to. I had no idea of the hospital’s hierarchy, no idea of the personnel and no idea of who was really interested in the education side of it either”.^[859]

391.    Teachers also described how psychiatric staff had devised a behaviour modification system. Anna Natusch said teachers were required to grade students from A to D based on their behaviour. Normally getting a low grade would result in some minor loss of privileges:^[860]

“At Lake Alice, however, I would be loath to give a D because I was aware of the dire consequences for the children. I was told upon being given the book that if a child had a small number of D ranks in a row, they would get electric shock treatment, without anaesthetic. It was appalling.”^[861]

392.    To protect her students, Ms Natusch said she manipulated their marks to spare them from punishment.^[862]

393.    Some of the teachers recalled the impact that medication had on their students’ learning. Ms Natusch told us, “Effects of the drugs that I witnessed in the children included sedation, drowsiness, lethargy, difficulty in thinking, poor concentration, nightmares, emotional dullness, depression and despair”.^[863] A 1977 school inspector’s report on Lake Alice confirmed the Department of Education was aware students were receiving treatments that “[could] affect their capacity to learn”.^[864]

394.    Evidence of paraldehyde administered as punishment was also in school reports. One student’s comment on her 1975 school report implied students were given a “needle” for misbehaving. She wrote: “I think I have done very good at school, and I have been a good girl at Lake Alice Hospital and I had the needle once.”^[865]

395.    Another teacher, Mr Craig Collier, recalled an incident during a concert where nurses openly threatened the use of ECT. At one point, he said, a young adult patient was attempting a classical piano piece that was going badly and the audience became unruly.

“Two nurses … then rolled an ECT machine onto the stage, which quietened the patients down. One of the nurses called out “If you don’t settle down, this is what you’ll get.” In my view, I would call this psychological abuse to which young adolescents should not have been exposed to.”^[866]

396.    Consistently, the teaching staff at Lake Alice school told us they did not act on concerns they had about the treatment of children and young people at the unit as they did not see it as their place to challenge the treatment decisions of medical staff. Even if they did want to complain, they told us they did not know who they could raise their concerns with.

Ngā amuamu ki te Department of Education - Complaints to the Department of Education

397.    In addition to the teaching staff at Lake Alice, the inquiry also reviewed evidence from several educational psychologists who had visited the Lake Alice school or been involved in some other way with the school between 1972 and 1978. Psychologists would assess students’ abilities and help teachers devise educational programmes. Most of these educational psychologists raised concerns with the Department of Education about what was going on at the school. They cited the use of ECT as punishment^[867] and the exposure of students to adult patients who displayed dangerous behaviour.^[868]

398.    Two of the psychologists, Mr Craig Jackson and Mr Don Brown, raised serious concerns about the unit early on after it was established. Mr Jackson visited the school monthly in the early 1970s. In a media interview in 1999, Mr Jackson said he was made aware of concerns about the misuse of ECT at the unit by teachers at the Lake Alice school. He said he alerted his superiors within the Department of Education to these concerns and was assured that they would be passed on to Dr Mirams, the Director of Mental Health at the Department of Health.^[869] Mr Jackson was initially hesitant to take the concerns further but over time the rumours became more persistent and he felt “an ethical duty to the boys to pass the information further up the hierarchy”.^[870] Despite assurances that the matter would be investigated, Mr Jackson said teachers at Lake Alice and other visiting psychologists continued to report similar concerns through until 1977.^[871]

399.    In September or October 1974, Mr Brown, the acting Chief Psychologist, called Mr Jackson to discuss allegations of improper use of ECT at the unit. Mr Jackson stressed he had no direct knowledge of this but was aware from discussions with the principal at Lake Alice school that electric shock treatment was seemingly being used in a punitive fashion.^[872] Mr Jackson also raised the matter with an inspector supervising special education at the Wanganui Education Board.^[873]

400.    In November 1974, Mr Brown visited Lake Alice where a staff member told him children and young people were given “aversion stimuli” such as paraldehyde injections in the buttocks and electric shocks to the legs.^[874] Based on this information, Mr Brown said he confronted Dr Pugmire and said:

“I was very, very concerned that it looked to me as though I was being told openly there were practices being used which apart from whether or not some degree of punishment was justified these were totally unacceptable forms of punishment.”^[875]

401.    Mr Brown asked Dr Pugmire for assurance that those sorts of things were not happening in the unit.^[876] Dr Pugmire did not give Mr Brown that assurance.^[877]

402.    Soon after Mr Brown’s visit, Dr Pugmire wrote to him saying he had reviewed Lake Alice’s various “therapeutic techniques” and found “nothing in the slightest degree disturbing or out of the ordinary”.^[878] Dr Pugmire told Mr Brown he could inform his staff that their “anxieties were completely unfounded”.^[879] Despite having asserted everything was in order, Dr Pugmire told Mr Brown that he and Dr Leeks had agreed to discontinue use of “Electrotonis [sic] and to always give an anaesthetic before ECT treatment”.^[880] Dr Pugmire also said the unit would “refuse all patients who require any form of aversion therapy and thus completely eliminate one source of mythology”.^[881] In addition, Dr Pugmire said he had “completely changed the nursing staff on the boys’ villa, including the Charge Nurse”.^[882] Unconvinced, Mr Brown said he wrote a report to the Department head office saying treatment at the unit was not satisfactory and referrals from the educational psychologists of children and young people to Lake Alice were stopped.^[883] We found no other evidence of action taken by the Department in response to these concerns.

403.    Dr Pugmire also replaced the staff in the unit, including the charge nurse,^[884] Mr Hunt was replaced by Mr Corkran. While Dr Pugmire told Mr Brown he had secured Dr Leeks’ agreement to stop giving aversion therapy and ECT without anaesthetic, we located nursing notes and received numerous accounts to show that unmodified ECT and aversion therapy continued being administered at the unit after 1974.

Next page -->