719.    Two main inquiries in the late 1970s contributed to the closure of the Lake Alice child and adolescent unit - an investigation by Ombudsman Sir Guy Powles and a commission of inquiry conducted by Magistrate William (Bill) Mitchell. The first was prompted by a complaint by Mr CD’s parents about his detention and treatment at the unit.^[1363] The second followed media coverage about Mr Hake Halo’s case.^[1364] Despite setting in motion the process that led to the unit’s closure, both inquiries faced limitations in fully or adequately exposing the abuse occurring at Lake Alice.

Te hōkaitanga o ngā tūhuratanga - Scope of the investigations

720.    The Ombudsman’s investigation and the commission of inquiry were limited to considering what had happened to an individual adolescent admitted to the unit. As neither inquiry undertook a wider investigation into what was happening at the unit, neither heard from other tamariki who may have provided accounts similar to those they were investigating.

721.    The Ombudsman had wide statutory powers to decide what issues to address and how he should do so. He could compel the provision of information, although the Act in force at the time^[1365] limited the Ombudsman’s ability to compel information subject to secrecy under most enactments. He was able to spend nine months gathering information from various sources including the responsible departments, the boy’s school and NZ Police. He obtained expert assistance from three professors of psychiatry, and employees within his office interviewed family members of the boy and various members of the clinical and social welfare staff who had looked after him.

722.    The commission of inquiry was constrained in time and its terms of reference. The magistrate’s terms of reference were to inquire into and report on:

• the authority on which treatment was administered to the boy by the medical authorities at Lake Alice
• any associated matters the magistrate considered relevant to the general objects of the inquiry.^[1366]

723.    The narrowness of these terms of reference may have been influenced by concerns the inquiry would turn into an evaluation of electroconvulsive therapy (ECT) as a legitimate therapy. In January 1977, Dr Stanley Mirams, the Department of Health’s Director of Mental Health, wrote to Dr Sydney Pugmire, the Lake Alice medical superintendent, to tell him it was “certainly the intention of [the Department of Health] to avoid any public inquiry into the suitability of ECT as a form of treatment”.^[1367] Some of the correspondence discussed below provides insight into the concerns felt among hospital staff and responsible agencies about what they perceived to be an attempt to undermine public confidence in psychiatry more generally.

724.    The terms of reference appear to have been settled quickly, the hearing was short, and the report had to be delivered within two months. The Hon. Patrick Keane, counsel for the Departments of Social Welfare and Health, recalled the inquiry as “a rapid and highly specific government response to December 1976 media criticism” concerning Mr Halo’s care under the guardianship of the Director-General of Social Welfare “at a time where there was a similar complaint with the Ombudsman”.^[1368]

Te urupare nō Lake Alice - Response from Lake Alice

725.    Lake Alice’s responses to both the Ombudsman’s investigation and commission of inquiry were sometimes less than forthcoming. Sir Guy was particularly unhappy with one incident at Lake Alice in November 1976. On the morning of a planned interview with Mr CD, Dr Leeks gave the boy unmodified ECT, leaving him “dazed and confused” and “unable to remember past events”, which made the interview “singularly unhelpful to the investigation.” Sir Guy’s first impression was that Dr Leeks’ actions may have been a deliberate attempt to prevent his office from carrying out its duties. He asked the Department of Health for an explanation.^[1369] Dr Leeks responded to Dr Pugmire:

“I saw no reasons why medical requirements should take secondary consideration over political expediency. [Mr CD] was involved in a course of treatment at two day intervals, and the appearance of a political or official agent of enquiry is of little importance compared to the treatment of a patient. [Mr CD] at the time though quieter and less violent was still not speaking to the pakeha contingent of the Unit, but communicating only with the Polynesian groups. In effect, as it happened, I consider it was perhaps a favour to the Ombudsman’s officer, although again this was secondary, as [Mr CD] was able to speak with the person concerned.”^[1370]

726.    The Deputy Director-General of Health, Dr Rod Barker, reviewed Dr Leeks’ response and wrote to the Ombudsman, saying the Department was “perturbed at Dr Leeks’ apparent failure to grasp the overriding significance” of the matters under investigation.^[1371] However, he said he had discussed the matter with Dr Mirams who assured him Dr Leeks would be motivated only by the consideration for his patient, and he did not think he would have any deliberate intention of obstructing the inquiry.^[1372] Dr Barker further noted that some psychiatrists regarded the effectiveness of ECT as being heavily dependent on carrying out the prescribed course of treatment.^[1373]

727.    After hearing explanations and comments from the director of the division of mental health, Sir Guy was satisfied there was not a deliberate attempt to interfere with the enquiry.^[1374] However, he said it was “unfortunate” the treatment had gone ahead on a day when the hospital knew well in advance that a member of his staff was coming to interview Mr CD.^[1375] “If proper consideration had been given at the Hospital and my office informed”, he wrote, “I could easily have arranged for my staff member to go on another day. I decided to not take this matter any further”.^[1376]

728.    On 22 December 1976, Dr Pugmire wrote to Dr Mirams responding to his request for an evaluation of why Mr CD had been given ECT before the interview and how it had been carried out.^[1377] Dr Pugmire said in his letter to Dr Mirams that they had previously had lengthy correspondence about Dr Pugmire’s difference of views with Dr Leeks about the care and treatment of tamariki in the unit:

“My view on the basis of success in the treatment of children is frankness and honesty in answering their questions, correct medication, just and simple rules of ward conduct plus an overall attitude of kindness.”^[1378]

729.    Dr Pugmire also pointed out in his letter that Dr Mirams had clearly set out the previous year that all clinical responsibility for the treatment at the unit fell to Dr Leeks.^[1379] Dr Pugmire also advised that he had recently discovered Dr Leeks had been using an ECT machine that Dr Pugmire thought had been condemned. He said it had become clear that Dr Leeks had continued to carry out ECT in the unit, rather than the ECT Department and without an anaesthetist.^[1380]

730.    Dr Pugmire said he had removed the outdated machine to safeguard the officers of the unit in any forthcoming inquiry, but after Dr Leeks insisted it was a clinical decision to continue to use the machine he had returned it.^[1381] Dr Pugmire said he did not want to be responsible for a machine he “did not like” and treatments he “did not know were occurring” in a place that was not “suitable” for giving ECT.^[1382] He said that Dr Leeks’ decision to continue giving ECT in the unit with the outdated machine was, by virtue of its lack of safeguards, “hard to defend” and “foolish”.^[1383]

731.    In relation to the commission of inquiry, Dr Pugmire wrote to Dr Leeks that it was “shrewd thinking on behalf of our faithful colleagues at Head Office to eliminate that question [regarding the appropriateness of ECT] from the Magistrate’s brief and to ensure that the hearing was secret and not for publication”.^[1384] He went on to say:

“It is my personal opinion that if the present enquiry had been dealing with ECT and had been a public enquiry in which every false allegation was headlined, both you and I by now might have been seeking employment in South America where our heinous imaginary crimes were unknown.”^[1385]

Te korenga o ngā tuaritanga kōrero a ngā umanga tika - Lack of information sharing by responsible agencies

732.    By 1977, the responsible agencies had received multiple complaints about the treatment of children and young people at the unit. In general, agencies took a defensive approach and were not forthcoming with material that could have assisted the investigation and commission of inquiry. This approach was inappropriate and limited the ability of the inquiries to see the full picture of abuse at the unit.

733.    For example, the Department of Social Welfare removed and edited information from Mr CD’s file after the Ombudsman had asked to see it.^[1386] The Ombudsman pressed the Department for an explanation, and the Department said a senior officer had “felt that the comments which he had removed had no relevance to the subject-matter of the complaint and should not in any event have appeared on the papers”.^[1387] The Ombudsman accepted the officer did not intend to obstruct his investigation, but he still regarded the officer’s actions as “extremely serious” and referred the matter to the State Services Commission, which issued a notice to public servants reminding them of the need always to provide all original documents the Ombudsman requested.^[1388]

734.    A second example was important contextual evidence regarding Mr Bryon Nicol the Department did not share. The office of the Director-General of Social Welfare asked Mr Michael Doolan, by then the Holdsworth School principal, for comment on Mr Nicol’s time at Holdsworth before he was sent to Lake Alice in 1973. Mr Doolan replied on 8 February, about a week before the magistrate’s inquiry began, saying the school’s records on the boy were “rather sketchy”.^[1389] Nonetheless, he wrote:

“I have no doubt that [the boy] did receive ECT while at Lake Alice – this seemed to be routine at the time. I have no doubt that he perceived the administration of ECT as a form of punishment – I had the same perception. As Assistant Principal at Hokio Beach School, I had a lot of contact with the Lake Alice Adolescent Unit. It was my very clear perception that:

ECT was administered to children held at the point of consciousness – thought to be very effective with those tamariki exhibiting explosive character disorders;

Nursing staff at the Unit used the threat of ECT as a method of behavioural control;  

Paraldehyde injections were used for similar reasons.

“It was because of these, and other misgivings that I had, that Holdsworth ceased the practice of referring lads to the Lake Alice Hospital Adolescent Unit at the end of 1973.” ^[1390]

735.    Mr Doolan concluded by saying he would be prepared to amplify the paragraphs quoted above should the Director-General wish him to do so.^[1391] This information was not shared with the inquiry. We contacted Mr Mitchell for comment and provided him with Mr Doolan’s statement. He told us:

“I am confident that, had I been aware of the concerns raised by Mr Doolan and it seems others, these issues would have been investigated by me as part of the inquiry. The information contained in Mr Doolan’s witness statement could well have changed my view as to the evidence regarding the use of ECT as a punishment.”^[1392]

736.    Instead, the Commission of Inquiry was left to deal with Mr Halo’s complaint of mistreatment without the benefit of further contextually relevant information. The examination of witnesses became a credibility assessment between a 13-year-old Pacific boy, who was perceived to have behavioural and psychological issues, and the responsible departments and a respected child psychiatrist. Mr Halo was not present or represented at the hearing.

737.    The Department of Education was also not forthcoming. It did not tell the inquiry its head office sent an educational psychologist, Mr Don Brown, to investigate allegations of misuse of the ECT machine in 1974.^[1393] Mr Brown’s report, which was critical of the unit’s use of ECT, was not supplied to the inquiry.

738.    While the above examples may not have been directly relevant to the treatment of the individual at the centre of the inquiry, they would have provided context as to growing concerns about the methods used at the unit. However, adverse publicity about psychiatry generally and about Lake Alice appears to have led those responsible for children and young people in the unit to take a defensive approach to the inquiries. The effect of the approach was to prioritise the reputation of the institutions and of psychiatry over openness and oversight.

Next page -->