Royal Commission of Inquiry into Abuse in State Care

The Royal Commission

In 2018 a Royal Commission of Inquiry was established into Abuse in State Care (the Royal Commission). Information about the Royal Commission can be found here .  

The Medical Council of New Zealand has assisted the Royal Commission by providing information and giving evidence in June 2021. Our evidence was about how the Medical Council responded to concerns about Dr Selwyn Leeks while he was working at Lake Alice hospital in the 1970s. 

Background information

About the Medical Council  

The primary purpose of the Medical Council is to protect the health and safety of the public by ensuring that doctors are competent and fit to practise. One of the ways we do this is by setting standards of clinical competence and ethical conduct while providing mechanisms to ensure that all doctors practise safely and competently, and act with the highest level of professionalism.  

Summary of Inquiry Findings 

The Royal Commission produced the Beautiful Children Report in 2023. In its summary of findings, the Royal Commission found that the “investigations and actions by medical professional bodies in 1977 were flawed.”

The Royal Commission also found that the Medical Council “accepted much of Dr Leeks’ response to allegations without question” and that the Medical Council “declined to carry out a fresh investigation into Dr Leeks’ conduct in 2000, wrongly believing earlier investigations had adequately addressed the issues.”

In its final report released on 24 July 2024, titled Whanaketia – Through pain and trauma, from darkness to light , the Royal Commission concluded that:

• The Medical Council did not always act to ensure people in care were safe from doctors who should not have been practising.
• The Medical Council was at fault for:
  • Not acting when it should have done to protect the public.
  • Making decisions in relation to complaints of abuse that it cannot now explain due to the incompleteness of records.
  • Accepting Dr Leeks’ response to allegations without question when investigating him in 1977.

Dr Leeks’ abuse 

Dr Leeks was practising as a psychiatrist in New Zealand in the 1970s when he abused children and adolescents under the guise of treatment. This took place at Lake Alice Hospital, an inpatient youth psychiatric facility in Manawatu. Allegations about Dr Leeks included that he:   

1. Misdiagnosed patients;  
2. Inappropriately medicated them;  
3. Threatened patients and carried out punishments for misbehaviour. The punishments included the use of electroconvulsive therapy (ECT) without anaesthetic, and the use of paraldehyde as an immobiliser;  
4. Secluded, unlawfully detained, and tortured patients.  

Survivors experienced what the Royal Commission’s report described as:   

Severe consequences for [their] mental health. Some who had no mental distress before being sent to the unit have since been diagnosed with a mental health condition. Long-term symptoms include uncontrollable outbursts of anger, memory loss, hypervigilance and a persistent fear of being sent back to Lake Alice, even though they know the hospital has long since closed.  

Many survivors reported becoming dependent on drugs and alcohol, sometimes from a young age, to numb the emotional pain and block out traumatic memories. As a result, many have been convicted for drink-driving and cannabis use. Some found the pain so unbearable they saw no option but to commit acts of self-harm or take their own lives.  Some survivors still carry physical scars and symptoms, including migraines and headaches from the electric shocks, back pain, and permanent bowel injuries from the sexual abuse.  

Less visible, but just as painful, effects on survivors include the weakening of whānau and traditional cultural bonds. Many Māori and Pacific survivors had trouble reconnecting with their whānau, communities and culture on release from the unit. Most survivors have said they don’t trust others. They tend to be deeply suspicious of those in authority and have difficulty forming healthy, long-term, intimate relationships. This suspicion of authority figures, together with a poor education, has resulted in many survivors struggling to get or hold on to jobs. One survivor had to leave his job because the sound of workplace machinery triggered memories of the ECT machine Dr Leeks used to abuse him.  

Dr Leeks was never disciplined for any conduct that took place while he was working at Lake Alice. Dr Leeks took a limited role in responding to the Royal Commission. He was elderly and very unwell and died in January 2022. 

Certificate of Good Standing (COGs) granted   

Dr Leeks applied for a Certificate of Good Standing in December 1977 for the purpose of becoming registered in Australia.   

• A COGS was issued by the Medical Council on 22 December 1977.   
• The COGS did not refer to any proceedings or previous investigations, as was the practice at the time – the previous investigation ended in November 1977.   
• A COGS would not have been issued if there was an investigation underway, or if Dr Leeks was subject to any Tribunal or Council order.   
  The Medical Council, and its predecessor organisations, considered notifications about Dr Leeks on three separate occasions.   

This resulted in two investigations; one notification did not reach an investigation:   

1. The Medical Council and the New Zealand Medical Association considered notifications about Dr Leeks in 1977.   
   •  The NZMA’s Central Ethics Committee referred the notification to the Medical Council’s Penal Cases Committee for investigation.  
   • The matter did not proceed past a Penal Cases Committee.   
   • A description of the regulatory environment then is set out on the Inquiry website. 
2. In 1991, the Medical Practitioners Disciplinary Committee considered another notification about Dr Leeks.  
   • This was found to be ‘not sufficiently substantial’ and did not proceed.  
   • A further complaint was made to the Council in 1999 and a Complaints Assessment Committee (CAC) was convened. A CAC is the equivalent of the current Professional Conduct Committee investigation.  
   • The CAC lost contact with the notifier and the investigation was concluded without any resolution.   

A disciplinary hearing was due to take place in Australia in June 2006. Dr Leeks provided an undertaking that he would not return to medical practice and the Medical Practitioners Board of Victoria decided not to proceed with the formal hearing.   
  
Dr Leeks’ name was removed from the Medical Council of New Zealand’s register in September 1999 because he had been out of New Zealand for more than three years.  

Could this happen again?  

The Council is currently conducting an external, independent review of the processes and actions it takes in response to concerns being raised about a doctor’s conduct. The review specifically relates to conduct notifications involving allegations of a doctor abusing a patient to identify whether issues arising from the Commission’s inquiry would be effectively addressed under the Council’s current processes and can be prevented in the future so that the protection of the public is assured.  

While complaint and investigation processes differ from those in the 1970s-1990s, the Council will consider the findings of the external review and along with any recommendations. 

Council's Temporary Committee

In 2023 the Medical Council established a Temporary Committee to consider the issues raised by the Royal Commission and respond to these. The Royal Commission’s final report is due to be released no later than 27 June 2024.  

The Temporary Committee has three members of the Medical Council (a medical member and two lay members), and two community members (who are not members of the Medical Council). Click here to see the members of our Committee. 

The Committee will consider the Royal Commission’s final report and recommend actions the Medical Council could take. This could include: 

1. Consideration of the findings of an external review of the Medical Council’s systems and notifications processes and the current provisions in the Health Practitioners Competence Assurance Act 2003 (HPCAA), to identify whether issues arising out of the Royal Commission’s report can be prevented in the future to assure protection of the public; 
2. A formal response to the Royal Commission’s recommendations (whether directed at the Medical Council or not); and 
3. Any other matters related to the Royal Commission. 

The Committee’s activities will be consistent with the HPCAA and will be guided by the Medical Council’s values.  The Medical Council’s values are:  

Whakapono – We act with integrity  
Whakamārama – We will listen to understand  
Manaakitanga – We will support each other  
Kaitiakitanga – We protect the public  
Kotahitanga – We will work together 

What the Medical Council is doing now

The Medical Council has agreed to: 

• Commission an external review of our notifications processes when a doctor is accused of abusing a patient.
• Provide a further apology to the Children of Lake Alice and to the New Zealand public.

Where to find support

The Royal Commission website refers to these providers for people engaging in their inquiry: 

• Alcohol and Drug Helpline  0800 787 797 or online chat for people dealing with an alcohol or other drug problem; 10 am to 10 pm)
• Anxiety phone line  0800 269 4389 (0800 ANXIETY)
• Depression Helpline  0800 111 757 or free text 4202 (to talk to a trained counsellor about how you are feeling or to ask any questions)
• Family Services 211 Helpline  0800 211 211 for help finding (and direct transfer to) community based health and social support services in your area.
• Lifeline  0800 543 354 (0800 LIFELINE) or free text 4357 (HELP)
• Need to talk?  Free call or text 1737 any time for support from a trained counsellor
• OutLine NZ  0800 688 5463 (OUTLINE) provides confidential telephone support for sexuality or gender identity issues; 9 am to 9 pm weekdays, and 6 pm to 8 pm weekends)
• Rape Crisis  0800 883 300 (for support after rape or sexual assault)
• Safe to talk  (Available 24/7) 0800 044 334, free txt 4334, email support@safetotalk.nz, live webchat on www.safetotalk.nz. Free and confidential information and support from trained counsellors for people affected by sexual harm in any way.
• Samaritans  0800 726 666
  Skylight, 0800 299 100 for trauma, loss and grief; 9am–5pm weekdays
• Suicide Crisis  Helpline 0508 828 865 (0508 TAUTOKO)
• Victim Support  This free service provides emotional and practical support, information, financial assistance, referral to other support services and advocacy for the rights of victims.
• Youthline  0800 376 633, free text 234 or email talk@youthline.co.nz or online chat.

Our apology

Dr Rachelle Love has apologised on behalf of Te Kaunihera Rata o Aotearoa | Medical Council of New Zealand.

In June 2021, our (then) Deputy CEO apologised on behalf of the Medical Council for the Council’s role in failing to hold Dr Leeks to account.

You can find our full 2021 apology here: 
Document Library | Abuse in Care - Royal Commission of Inquiry .

A transcript of our evidence before the Royal Commission can be found here . 

The Royal Commission’s website also contains other evidence filed – you can find this here:
Our progress | Abuse in Care - Royal Commission of Inquiry .