893.    After the 1977 investigation, NZ Police conducted a series of investigations that can be divided into three phases. The first phase stretched over a three-year period from 2003 to 2006. The second was, in effect, a continuation of the first, but led by a new officer, and lasted four years, from 2006 to 2010. The third began in November 2018 with a single complainant before widening to two complainants and eventually extending to every Lake Alice survivor who had made a complaint to NZ Police. It ended three years later in December 2021.

Tūhuratanga tuarua: 2003 ki 2006 - Second investigation: 2003 to 2006

894.    On 7 March 2002, with the second round of Crown settlements complete, Grant Cameron Associates, with the claimants’ consent to do so, submitted to NZ Police the statements, medical files and nursing notes of 34 claimants, along with corroborating evidence from other witnesses, and asked NZ Police to investigate the allegations of criminal conduct contained in this material.^[1714] Superintendent Graham Emery reviewed the material and concluded the complaints had “substance” and needed to be “thoroughly investigate[d]”, noting that “in many cases ECT was for behavioural problems, not as treatment but rather for punishment purposes”.^[1715] Mr Emery considered NZ Police should, for “public interest reasons”, investigate the various complaints made by ex-patients of Lake Alice.^[1716]

895.    It was not until 15 months after receipt of the documentation from Grant Cameron Associates that an investigation began. On 12 June 2003, Detective Superintendent Larry Reid, based at NZ Police national headquarters in Wellington, was assigned the investigation file. Deputy Commissioner Stephen Long attached a hand-written direction to seek an opinion from Crown Law.^[1717]

896.    The second investigation proceeded without reference to the 1977 investigation. Mr Reid was not aware of the previous file, and the 2003 investigation was not given priority.^[1718] While responsible for the investigation, Mr Reid led other investigations and allocated resources to major inquiries. He also relieved for a period as national crime manager.^[1719] He told us it was a very busy role, he had many other matters that needed to be dealt with and the Lake Alice investigation was handled on an “as available basis”.^[1720]

897.    The first step he took was to seek an opinion from Ms Nicola Crutchley, Deputy Solicitor-General, at Crown Law in June 2003. However, it was evident from the outset Mr Reid did not consider an investigation was warranted and he conveyed this to Ms Crutchley.^[1721] He passed on to her documentation relating only to Mr Halo’s complaint. He explained to another of the complainants that Mr Halo’s case “capture[d] the intent and general allegations of other complaints”.^[1722] However, this was not accurate. Mr Halo complained he had been given electric shocks to his head, whereas others complained of electric shocks to other parts of the body, and many also complained of serious sexual and physical abuse. By submitting a single complaint, he also failed to reveal the systemic nature of the alleged abuse, a criticism subsequently levelled by the United Nations Committee against Torture.^[1723]

898.    Crown Law’s opinion did not arrive until April 2004, almost 10 months later. Mr Reid was waiting for Crown Law advice and took no investigative steps in the interim. Ms Crutchley’s opinion was unambiguous. There was insufficient evidence at present to justify laying criminal charges, but NZ Police should investigate further given the nature of the allegations. She said she had little doubt that if claimants had received ECT (or more accurately electric shocks) as punishment, this would be “reprehensible conduct, and quite likely, criminal behaviour on the part of those responsible”.^[1724] Ms Crutchley advised NZ Police to conduct further inquiries to ascertain whether there should be a detailed investigation. She suggested a number of enquiries to be undertaken. None of these was done until 2006.^[1725]

899.    In September 2004, Inspector Jim Taare was instructed to look into Mr Halo’s complaint. He prepared an 11-step investigation plan, interviewed Mr Halo and a former school teacher, Ms Anna Natusch. In Mr Taare’s report, he concluded sufficient evidence existed to start a criminal investigation and considered Ms Natusch to be a credible and reliable witness.^[1726]

900.    We do not know whether NZ Police took any notice of Mr Taare’s report during their investigation as his report, like many other documents relating to this investigation, has gone missing. No file was entered into the central database in operation at the time, so several file documents were not saved and can no longer be found.^[1727] Poor file management practices extended to the loss of statements and supporting evidence provided by 14 of the 34 complainants.^[1728] NZ Police acknowledged to us it is “unknown whether any investigative steps were taken in respect of these complaints, but it appears unlikely”.^[1729] One statement from a survivor who alleged Dr Leeks had raped her was lost.

901.    Mr Reid undertook no investigative work until early 2005 when he incorrectly recorded in a weekly report, dated 18 March 2005, that Crown Law had advised him against investigating the misuse of the ECT machine and paraldehyde any further.^[1730] He wrote that “these former patients are also alleging that ECT and a drug called paraldehyde was used inappropriately at Lake Alice however [the Crown Law] opinion provided to me really dismisses this issue from criminal investigation”.^[1731] Mr Reid’s incorrect interpretation of Crown Law’s advice led him to consider the only allegations remaining to investigate were those involving sexual and physical abuse.

902.    Following from this, Mr Reid drew up a schedule of the survivor statements, based on the 20 remaining statements held, that alleged physical or sexual abuse. He described the allegations in each statement and listed the alleged offenders, if identified. Six men were named. His descriptions of the allegations did not reflect the serious nature of the sexual offending in particular. In respect of one survivor, for example, he simply recorded “sexual assault”.^[1732] In fact, the survivor’s statement contained detailed descriptions of sexual violation by unlawful sexual connection, both oral and anal, on numerous occasions by two offenders.

903.    Rather than interview complainants to get a full account of their allegations and identify potential lines of inquiry, witnesses to speak to, and the availability of corroborative evidence, Mr Reid made only cursory inquiries about the location of former staff. He took no further steps to speak to them. He did not contact or interview any of the complainants, he did not identify or interview other witnesses, he did not seek out hospital files or records, and he did not locate or interview suspects. NZ Police conceded to us in 2021 that, from 2002 to 2006, they did not actively progress any of the complaints.^[1733]

904.    The disinclination of NZ Police to investigate the allegations was particularly evident in the case of Ms Sharyn Collis, who alleged Dr Leeks raped her while she was at the unit. Records show her lawyer wrote to NZ Police twice to try to initiate action on her complaint – a complaint Ms Crutchley had specifically mentioned in her opinion to NZ Police. Ms Collis’ lawyer, Mr Steve Winter, wrote first in October 2004 and again 10 days later. NZ Police eventually replied in February 2005 saying they had no record of her complaint but could interview her, although they never did.^[1734]

905.    Perhaps the clearest evidence of NZ Police inaction can be found in a weekly report Mr Reid wrote in March 2005, in which he said, “it is my strong view that none of the complaint/allegations I have without a direct and unequivocal confession from the suspect (where one can be identified) would reach evidential standard to even consider a prosecution.”^[1735] Mr Reid told us:

“I have been involved in many criminal prosecutions. Without corroborative evidence, the focus inevitably shifts to the credibility of the complainant. The troubled lives of the complainants led to their attention at Lake Alice, many of whom unfortunately went on to have criminal convictions and the like. In my view, it would have been unfair and improper to the complainants to put them in that situation without strong supporting corroborative evidence.”^[1736]

906.    Mr Reid, however, made these observations about the credibility of dozens of complainants’ without having first conducted an interview or taken any steps to investigate their complaints in any substantive way.

Tūhuratanga tuatoru: 2006 ki 2010 - Third investigation: 2006 to 2010

907.    Detective Superintendent Malcolm Burgess inherited the NZ Police investigation in April 2006 from Mr Reid. One of his first actions was to prepare a comprehensive investigation plan that had five objectives.
These objectives were to:

• investigate the allegations by 35 complainants subjected to “unlawful” ECT at the unit between 1972 and 1977^[1737]
• investigate specific allegations of sexual assaults and other violations by named suspects during this time
• determine whether there was enough evidence to press criminal charges
• follow best-practice guidelines
• ensure the investigation team met all its legal obligations.^[1738]

908.    The plan detailed the tasks that would be necessary to meet the objectives. It also said a full inquiry team would be needed to complete these tasks, namely, a detective sergeant, four investigators and an analyst.

909.    Mr Burgess submitted the plan to Assistant Commissioner Peter Marshall on 22 June 2006 for approval.^[1739] It was not approved. After discussions with Mr Marshall, he and Detective Superintendent Nick Perry decided the plan would demand too many resources and that Mr Burgess would have to conduct the inquiry on an ad-hoc, part-time basis, drawing on a small handful of officers as and when he could fit this work around his other duties.^[1740] Mr Burgess and Mr Perry decided to focus the inquiry’s scope on Dr Leeks and the misuse of the ECT machine. This meant allegations against others who had worked at the unit and allegations of sexual and physical abuse, as well as the punitive use of paraldehyde, whether by nurses or Dr Leeks, were not properly investigated.^[1741] This decision was made despite Mr Burgess and Mr Perry being aware of allegations of “significant sexual offending”^[1742] and that staff members were probably also parties to offences of wilful ill-treatment of a child.^[1743] Mr Marshall endorsed this narrowed approach.^[1744] As a result of failing to receive approval for his comprehensive investigation plan, Mr Burgess could only continue the same under-resourced, low-priority approach his predecessor had adopted.

910.    Detective Superintendent Tom Fitzgerald told us NZ Police did not “accord sufficient priority and resources to the investigation”.^[1745] However, he did not explain why a low priority was given to a case involving serious allegations by a large number of complainants about so many suspects. NZ Police could not explain to us why they did not designate the investigation a “specialist investigation”, which would have resulted in the allocation of specialised investigating officers and greater resources. NZ Police told us they accepted they should have given it such a designation.^[1746]

911.    NZ Police apologised that “not all allegations were thoroughly investigated”.^[1747] However, it does not appear any allegations were properly investigated. The handful of interviews NZ Police carried out with former staff were general in nature, they did not gather highly relevant and corroborative hospital and social welfare files, and they excluded from their investigation serious allegations of offending by other staff. NZ Police apologised for their failure to investigate paraldehyde, but made no mention of their failure to investigate any allegations of sexual offending.^[1748] The NZ Police apology failed to reflect the full gravity of the investigation failures, which we now examine in more detail.

Te ngoikoretanga ki te whakapā atu me te uiui i ngā kaiamuamu - Failure to contact and interview complainants

912.    One of the NZ Police policies in place at the time governed investigations of sexual assaults. It said, “consultation with the victim is a priority throughout the investigation process, and decisions must be made in consultation with the victim and the [investigation’s adult sexual assault co-ordinator]”.^[1749] Mr Burgess accepted complainants were not interviewed.^[1750] Officers were required to make initial contact with complainants and confirm their willingness to take part in the investigation. He said NZ Police did not contact complainants out of concern they might not welcome an approach after such a long delay between submitting their statement and hearing from NZ Police.^[1751] They maintained this belief despite two complainants expressly asking NZ Police to investigate their complaints. During the next four years, NZ Police spoke to only one complainant, and only after he had initiated contact. They failed to interview any other complainants and they failed to even advise them they were looking into their complaints. Nor did NZ Police check whether complainants had access to wellbeing support services.

913.    NZ Police conducted the investigation on the basis of statements prepared for civil litigation, not criminal prosecutions, which require a higher evidential standard. More fundamentally, their failure to interview complainants meant they lost the opportunity to gather further information to initiate other lines of inquiry. The process by which NZ Police determined whether they had enough evidence to prosecute was deeply flawed and led to the irretrievable loss of some corroborative evidence.

Te ngoikoretanga ki te tūhura i ngā hara ā-taitōkai - Failure to investigate sexual offending

914.    The statements in the police file when Mr Burgess took over the investigation contained, as he conceded, “multiple allegations … of some pretty horrific sexual matters”.^[1752] Among the alleged offences were sexual violation by rape, sexual violation by unlawful sexual connection (anal and oral), indecent assaults and electric shocks to the genitals and breasts. The complainants were aged 10 to 16 at the time.

915.    One of the complainants was Ms Collis, whose lawyer had tried to have Mr Reid investigate her allegation that Dr Leeks raped her. Mr Burgess told the inquiry he had examined Ms Collis’ statement and while he accepted that Ms Collis believed she had been raped he considered there were evidential difficulties’ with proving her allegation. He took no further action concerning her complaint. It was not until 2018, 16 years after receiving her statement, that NZ Police interviewed her.

916.    In 2008, a former detective sergeant, Mr Dave Pizzini, conducted an independent review of the investigation file and found 11 possible steps NZ Police had failed to take.^[1753] When we asked Mr Burgess to comment on this finding, he said the passage of time had “significantly limited” many of these 11 potential lines of inquiry.^[1754]

917.    We asked Mr Burgess to explain why he failed to investigate any of the allegations, and he told us:

“Some were so vague that the details of the offending and the alleged offender could not be established. In two cases, the staff member was dead, [and] in one case the complainant was dead. Some allegations were not sufficiently credible to pursue, given conflicting evidence from the medical notes and no other corroborating evidence.”^[1755]

918.    He conceded, however, that NZ Police could have addressed any lack of detail in the statements by interviewing the complainants^[1756] and that it was inherently difficult to assess the adequacy of evidence to support a criminal charge without following this standard procedure.^[1757] In short, NZ Police were in no position to assess the adequacy or credibility of evidence without having taken that most basic of investigative steps – interviewing complainants, let alone taking any other rudimentary steps in an inquiry.

Kāore a Ngā Pirihimana o Aotearoa i tūhura i te whakatuakitanga o ngā kaimahi - NZ Police failed to investigate staff culpability

919.    The decision to focus solely on Dr Leeks meant NZ Police did not investigate the role of other staff in administering electric shocks and paraldehyde as punishment or the allegations against staff of physical or sexual assaults. Interviewing officers were instructed to speak to former staff in a general way about the unit and to invite them to comment on a list of complainants and “any psychotic condition [they] may have displayed during their stay”. Mr Burgess explained that the intention was not to interview staff members in detail “at this stage” about any specific allegations made against them by complainants.^[1758]

920.    We can only speculate about how many lines of inquiry might have opened up if NZ Police had carried out proper interviews with staff, but we have no doubt the tentative and undemanding nature of the questions officers put to staff members diminished the quality and quantity of evidence available to senior officers in deciding whether to investigate further or prosecute.

Ngā ngoikoretanga i te pūrongo i tukuna kia kupu ā-ture - Flaws in report submitted for legal opinion

921.    By September 2009, the investigation was coming to an end, and Mr Burgess prepared an investigation report, which he sent to Mr Ian McArthur, manager of NZ Police’s southern region legal services, for a legal opinion on the “public interest and abuse of process issues in regard to any potential prosecution”.^[1759] Mr Burgess wrote that he considered seven complaints appeared to have sufficient evidence to justify a prosecution.

922.    However, the impact of the NZ Police decision not to implement Mr Burgess’ comprehensive investigation plan from mid-2006 was reflected in Mr Burgess’s report to Mr McArthur. This in turn, strongly influenced the legal opinion Mr McArthur wrote, which was to oppose prosecution. Mr Burgess’ report made no mention of the lack of evidence on which to base a decision about whether to prosecute, although he made references to the need for further investigation if Mr McArthur decided there was a public interest in pursuing a prosecution.

923.    The report also contained inaccuracies and omissions about what little evidence NZ Police had collected. It referred, for example, to a “group incident” in which one boy was subjected to a series of electric shocks by Dr Leeks and a group of other boys, but it failed to mention that a nurse, Mr Terrence Conlan, had told Mr Burgess he witnessed Dr Leeks applying the electrodes of an ECT machine to the boy’s genitals and thighs.^[1760] It also failed to explicitly mention that expert evidence had confirmed this had never been medically accepted practice.

924.    The expert was Dr Garry Walter, on whom the Crown had relied previously to defend civil litigation by survivors. NZ Police asked Dr Walter for an opinion on the appropriateness of Dr Leeks’ medical practices. He replied with a 10-page opinion stating:

• the use of an ECT machine to give aversive therapy had never been medically approved
• placing ECT electrodes on parts of the body associated with offending behaviour had never been medically accepted practice
• giving unmodified ECT to patients, including children and young people, was, by the 1970s, no longer considered appropriate
• it had never been acceptable for a doctor to permit children and young people to administer electric shocks to another patient
• Dr Leeks’ treatments appeared to depart significantly from the standards of the day.

925.    Dr Walter’s opinion was a clear rejection of the practices employed by Dr Leeks and his staff, yet it received only brief mention in Mr Burgess’ report. He merely noted that “an expert opinion regarding the use of ECT to children has been obtained and is attached to the file”.^[1761] That relegation of such important evidence had a significant impact on Mr McArthur’s opinion as well as on a subsequent one sought by NZ Police from Mr Philip Hall QC, since neither made any reference to Dr Walter’s expert opinion. Mr Burgess conceded to us that neither had read Dr Walter’s opinion.^[1762] At the very least, Mr Burgess should have included a summary of Dr Walter’s opinion.

926.    Mr Burgess’ report also failed to mention the evidence of staff who confirmed Dr Leeks and nurses gave shocks as punishment. This included evidence by a nurse, Mr Brian Stabb, who gave Mr Burgess copies of his previous statements about the unit, in which he explained the clear distinction between the aversion therapy he had observed in England and the practices Dr Leeks employed at the unit, which he described as “barbaric”.

Ngā kupu ā-ture i tukuna ki te tūhuratanga - Legal opinions provided to the investigation

927.    Mr McArthur told us he had relied solely on the contents of Mr Burgess’ report.^[1763] Mr Hall, was later asked to review Mr McArthur’s opinion. He told us he chose to provide his opinion on the basis of Mr McArthur’s opinion and Mr Burgess’ report, and did not consider it was necessary to review the other information held on the file.^[1764]

928.    Mr McArthur failed to make any reference to evidence by Mr Stabb or other staff. Instead, he characterised staff as exhibiting “personal and professional care towards their charges, sharply contrasting with the negative assertions provided by the complainants”.^[1765]

929.    Mr McArthur’s opinion was largely based on his belief that it would be difficult to establish whether the methods employed by Dr Leeks and his staff constituted appropriate medical treatment in the 1970s, given that, as he understood it, using an ECT machine to carry out aversion therapy was an acceptable practice – a misunderstanding he demonstrated when he wrote, “The difficulty here is that the correlation between misbehaviour and administration of ECT is also entirely consistent with the theory of aversion therapy”.^[1766]

930.    As we have made clear, Mr Burgess made little reference to Dr Walters’ opinion in his report to Mr McArthur, but it was available to Mr McArthur. Had he read Dr Walter’s opinion, he would not have made such an error; nor would he have written that the “argument supporting a criminal prosecution is based solely on distinguishing applications of ECT as a punishment, rather than as treatment. Such an argument relies very heavily on clear evidence from the victims. Given the passage of time, this would, in my opinion, be extremely difficult to prove beyond reasonable doubt”. Asserting the Crown would have to rely heavily on victims’ testimony revealed another deep misunderstanding. Quite apart from the fact Dr Walter’s evidence showed the use of the ECT machine by Dr Leeks and his staff was unwarranted and unjustified, he also had corroborating evidence from nursing notes and statements of other patients and staff.

931.    Mr McArthur assessed the public interest in proceeding with prosecutions as follows:

“The fact that the events occurred many years ago and the victims have  received a government pardon and civil compensation for the wrongdoing, may reasonably be considered as meaning that many of the general public are of the view that the victims’ allegations have been taken seriously, and have been adequately addressed by the courts and the government.”^[1767]

932.    He, therefore, concluded “it would not be in the public interest to commence proceedings against Dr Leeks”.^[1768]

933.    The Crown stated to us that the inquiry had collected significantly more evidence from survivors and experts than was available to NZ Police at the time,^[1769] but the material we collected has always been available to NZ Police. They needed only to investigate the complaints properly to find it.

934.    Mr Hall’s review of Mr McArthur’s opinion was also flawed because he too relied on the same limited material.^[1770] He referred to “divided medical opinion as to what was appropriate treatment in the 1970s”, as well as a “strong body of evidence from staff who worked with Dr Leeks that his administration of ECT was treatment rather than punishment in order to modify behaviour”.^[1771] He went on, “Dr Leeks would be able to call medical opinion that his use of ECT as aversion therapy was justified in the treatment of young patients in the 1970s who exhibited the mental and/or behavioural problems of the alleged victims”.^[1772] But the “strong body of evidence from staff” was no more than a small sample of self-serving accounts from staff, which he accepted uncritically.  Like Mr McArthur, Mr Hall did not read or refer to the expert evidence of Dr Walters, and the expert psychiatric evidence Dr Leeks would be able to call on in support of his practices was non-existent. He said Dr Leeks’ culpability “must be low” and “there is little or no independent evidence that Dr Leeks acted in bad faith or without reasonable care towards his patients”.^[1773]

935.    In December 2009, Mr Hall told NZ Police he had reached the same conclusion as Mr McArthur that a prosecution would be unlikely to succeed and it would not be in the public interest to prosecute Dr Leeks.^[1774] Mr McArthur and Mr Hall drew conclusions in the absence of Dr Walter’s expert opinion. If Mr Burgess had properly presented Dr Walter’s opinion in his report, it would likely have affected the legal opinions reached.

936.    On 30 March 2010, NZ Police issued a press release saying they had decided after a “lengthy” investigation that evidence was “insufficient” to justify a prosecution.^[1775] Complainants had little option but to accept the decision because, as Ms Tracy Hu, a lawyer for survivors, noted, there was no accessible avenue for complainants to challenge a decision by NZ Police to refuse to bring a prosecution.^[1776] In theory, such a decision can be challenged by judicial review, but this is hardly realistic for most complainants. In our view, the lack of a realistic mechanism to challenge such a decision is a gap that warrants further attention.

Te haukume ki ngā kaituku amuamu - Bias against complainants

937.    From the outset in 1977, NZ Police demonstrated a bias against those admitted to the unit, and it influenced their assessments of complainants’ worth and credibility, which in turn influenced how vigorously or otherwise they investigated claims of abuse, and ultimately whether to prosecute the alleged perpetrators. The bias persisted, albeit wrapped in different language, after the patients at the unit grew into adults, but the results were the same: prosecutions failed to materialise – with a single exception in 2021, more than 40 years after the unit closed. 

938.    As we noted in our review of the 1977 investigation, Mr Butler was soon completely persuaded by Dr Leeks’ version of events, in which the unit was populated by “bottom-of-the-barrel kids” who were “anti-social and destructive”.^[1777] Some of the staff had similarly low views of patients’ worth, one describing them as “young thugs”.^[1778] Mr Trendle called them “a fairly dangerous collection of individuals”.^[1779] Throughout this period racism, ableism, homophobia and transphobia were pervasive, reflected in the rapid growth of Māori within the prison system and the persecution of Pacific communities during the dawn raids.

939.    Mr Butler’s reports described allegations in sceptical terms, highlighting that it was possible complainants were not telling the complete truth about why they received aversion therapy.^[1780] He labelled one young person “vindictive” for no other apparent reason than that he had made allegations against Dr Leeks.^[1781] He wrote that those receiving electric shocks were “uncontrollable” types from Department of Social Welfare homes, and he had “no doubt the majority of the boys concerned were of the worst anti-social and character-disordered types”.^[1782] By the end of his investigation, he was asserting that Dr Leeks had been made a “scapegoat”.^[1783]

940.    The discrediting of accusers as troublesome and unreliable was matched by a blanket assessment of staff as well-meaning, dedicated professionals doing difficult work under trying circumstances. Against this backdrop, it is hardly surprising NZ Police failed to investigate allegations impartially and comprehensively.

941.    In later years, the language in NZ Police reports changed but the underlying attitudes did not. There were references to complainants’ criminal histories and alleged addictions and substance abuse, which made it easier to downgrade assessments of their credibility. Mr Reid mentioned the criminal history of three complainants in the same breath as he described complainants as having “very low credibility”.^[1784]

942.    Mr Burgess’ first entry in the investigation file noted that complainants came from “disadvantaged or dysfunctional backgrounds”, and that many had ended up in prison and other institutions after leaving Lake Alice, so “issues of credibility” were “bound” to arise. He acknowledged “significant corroboration of the complainants’ allegations in the medical notes and patient files”, yet he still maintained complainants’ credibility was questionable.

943.    One reason cited for dramatically reducing the size of Mr Burgess’ investigation was “the significant number of the complainants suffering from psychiatric illnesses”.^[1785] However, we know very few had a psychiatric illness. We asked Mr Burgess to explain why he considered a psychiatric illness affected an individual’s credibility, and he said it was one of the things taken into account by officers to evaluate complainants. He conceded it was not something officers were taught as part of their training.^[1786]

944.    The legal opinions of Mr McArthur and Mr Hall also revealed they treated the accounts of staff as credible and those of survivors as questionable. The only material Mr McArthur sought from the investigation file were some staff accounts. He ignored the survivors’ accounts. He wrote that there were “issues of credibility for a number of the ex-patients arising from ongoing addictions, substance abuse and criminal offending”. We asked him to explain how he arrived at this observation, and he said it was based on his general knowledge at that time, formed in the course of more than 30 years of policing. He agreed, however, that Mr Burgess’ report contained nothing to suggest survivors had addiction or substance abuse problems. Mr Hall, like Mr McArthur, unquestioningly accepted staff accounts are credible. He said that “on any view of it [Dr Leeks’] culpability must be low on the basis of the medical practices at the time and the evidence of other members of staff”.^[1787]

He aha i puta i muri i te tūhuratanga - What happened after the investigation

945.    Three years after the conclusion of Mr Burgess’ investigation, on 3 November 2013, NZ Police conducted their first interview of a complainant from the unit that complied with evidential interview procedures. Mr Stephen Watt went to Levin’s police station and described how he witnessed an instance of prolonged abuse of a Niuean boy at the unit for stealing some cash. He gave the names of eight other patients and four staff who had also witnessed the incident.

946.    Detective Inspector Doug Brew reviewed the report before sending it to Mr Burgess, who was by now an Assistant Commissioner. Mr Brew, in a memorandum, described having previously interviewed and recorded the statements of former patients at the unit. This was inaccurate.^[1788] Mr Brew concluded the allegation was unsubstantiated and contained no “new or compelling evidence” to justify further investigation.^[1789] Mr Burgess received the report and Mr Brew’s assessment, and in March 2014 he concluded Mr Watt’s complaint disclosed no offence because the 1977 commission of inquiry had already looked into the matter and found no fault on the part of Dr Leeks.^[1790] This was not so. The inquiry had not examined the incident. As a result of the two officers’ assessments, no further action was taken. The investigation was closed.

Tūhuratanga tuawhā: 2018 ki 2021 - Fourth investigation: 2018 to 2021

947.    In June 2017 the National Adult Sexual Assault Team became aware of the Lake Alice file as a result of an Official Information Act request made by an investigative journalist. In October 2018, after reviewing material held, NZ Police made the decision to reinvestigate sexual complaints from former patients of Lake Alice who wished their complaint to be investigated. In November 2018, survivor Mr Malcolm Richards contacted NZ Police to make a complaint of sexual violation but was unable to name the perpetrator. NZ Police told him there was “little benefit in taking a new statement from you in regards to being sexually assaulted while at Lake Alice, as you are unable to identify the person or persons that sexually assaulted you”.^[1791] Mr Richards also complained about Dr Leeks giving him electric shocks on his genitals and was told “similar allegations made by other patients were considered in the 2006 investigation completed by Assistant Commissioner Burgess. At this stage Police are not going to be reinvestigating complaints around the use of ECT treatment by Dr Leeks”.^[1792]

948.    In December 2018 NZ Police interviewed Ms Collis and commenced an investigation into her complaint. In February 2019, NZ Police changed their position and contacted Mr Richards to say he could now make a new statement. The following month NZ Police interviewed him, along with another survivor, Mr Zentveld, who had complained that he, too, had been given electric shocks on the genitals.^[1793] On 15 March 2019, Detective Foley, one of the officers who interviewed Mr Zentveld, described him as a credible person and said “the circumstances in which the [electric shocks] occurred made it very clear that the complainant was being assaulted and that it was not a medical treatment or procedure”.^[1794] This was the first time an officer had spoken so plainly about what survivors had been subjected to in the name of ECT and aversion therapy.

949.    Mr Zentveld, Mr Richards, and Ms Collis were formally interviewed between December 2018 and March 2019 and separate investigation files were created. Identified enquiries were undertaken by NZ Police staff before the files were forwarded to the national adult sexual assault team at NZ Police national headquarters, which had agreed to co-ordinate the investigations.

950.    An updated opinion was obtained from Dr Walter because 10 years had passed since he provided his initial opinion. He said:

“It remains my opinion that applying electrodes on the genitalia of children as a form of aversion therapy was not an accepted medical practice in the 1970s, and is not an accepted medical practice now, and that in no way could this be justified as medical treatment.”^[1795]

951.    NZ Police were considering seeking a second opinion in the months that followed when the United Nations Committee against Torture released its decision in December 2019 that New Zealand had been in breach of its obligations under the Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment by failing to investigate Mr Zentveld’s complaint.

952.    The committee’s decision prompted NZ Police to absorb the statements made by Mr Zentveld and Mr Richards, and a third made by Ms Collis, into a much wider investigation that began in February 2020 examining all Lake Alice allegations. On 8 December 2021, NZ Police announced the outcome of their investigation, which was to charge former nurse Mr Corkran with nine charges of wilful ill-treatment of a child. ^[1796]  NZ Police also found sufficient evidence to charge Dr Leeks and another nurse with wilful ill-treatment of a child. Neither was charged because each was deemed medically unfit to stand trial.^[1797] 

953.    NZ Police tried to locate every former patient who had already given them or another organisation a signed statement. They did not try to reach former patients who had not made contact with them. Mr Fitzgerald, who was in charge of the investigation, told us NZ Police made the decision to avoid causing renewed distress to individuals who might be revictimised by such contact.^[1798] NZ Police contacted 102 individuals, 63 of whom said they wanted to be interviewed, 19 declined to be interviewed but agreed to the use of their previous statements, and 20 declined to be interviewed or have their previous statements used.^[1799]

954.    The desire of NZ Police to spare victims further anguish by contacting only those individuals who had previously contacted them or another organisation on their own initiative is understandable. However, this was the final opportunity to uncover the full extent of abuse at the unit and the decision not to actively contact everyone who had been at the unit may have diminished the amount of evidence potentially available, especially from disabled survivors whose experiences at the unit we know little about. Their decision not to screen all potential victims was contrary to the NZ Police policy on investigating mass allegations, which includes allegations about historic cases.^[1800]

955.    More than 40 years passed before NZ Police finally acted on the steady stream of complaints about Lake Alice and laid charges. The fact only a single individual was charged is the direct result of this delay and the inadequacy of earlier investigations. Not one staff member faced sexual abuse charges, despite the scale of sexual offending at the unit, because NZ Police decided not to investigate sexual allegations before them in the 2000s at a time when at least two alleged offenders, Dr Leeks and Mr Lawrence, were alive. For survivors and their families, this represents a loss of opportunity to obtain a key element of redress - accountability of perpetrators.

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