“As a human being, as a dad, as Prime Minister, I’m really sorry about what’s happened there because I can only imagine what that family has gone through in what was an absolutely horrific set of circumstances.
“I think we were all quite heartbroken about that story when we first heard about that.”
Asked whether compensation was being considered, Luxon said Doocey would “give due consideration to all of those issues in due course”.
In a statement, the girl’s family said the reviews had confirmed their “worst fears”.
“If we did what the state has done, we’d be locked up.
“Imagine how you would feel if your autistic daughter was handcuffed, physically restrained, held down by five people, and injected with anti-psychotic medication not once, but twice?
“Then being told she was injected for her own safety which is proven to be unlawful when the true facts finally come out over one year later?
“No whānau should ever have to learn that this is how their autistic child was treated at a time when she needed compassion, understanding, and support.”
The family said the incident had had an “enduring and detrimental impact” on the girl.
“She still has traumatic flashbacks as she feels unsafe in her daily life when we have worked so hard to help her to be okay in a world not designed for her.
“Much of that trust was shattered by what happened.”
The family listed a series of requests, including a formal public apology from Luxon, Cabinet and the ministers responsible for health, mental health, disability issues, police and Māori/Crown relations.
They called for “accountability” from public health entities and executives in health and police.
They sought an “independent, system-wide review on disabled people’s experiences across government agencies, and reform to ensure autistic people were better protected by the Government”.
How did the incident happen?
The 11-year-old girl, who is Māori and is referred to in the report as “Person A”, was diagnosed with autism and described in the report as “essentially non-verbal”, using only a few words or phrases. She was known to leave her house and wander for up to several kilometres.
The woman she was misidentified as was a 20-year-old Māori woman, referred to as “Person B”. This woman was known to Waikato-based mental health services and had a history of treatment for psychosis, including intramuscular injection.
In 2024, the woman was placed under a six-month compulsory treatment order and discharged to a supported accommodation service. She later went on leave and didn’t return to the service or engage further with mental health services.
The incident began early on March 9 last year when Hamilton police received a 111 call about a person seen walking in the middle of the road just before the Fairfield Bridge, which spans the Waikato River, and then climbing on the rails of the bridge.
The description included that the person was a woman in her early 20s.
The girl was the subject of the 111 call but could not be identified by police, who later handcuffed her as she became “increasingly distressed”. The inquiry deemed that action was warranted, given police concerns about her fleeing or self-harming.
Officers who responded to the callout floated the idea that the girl could be “Person B”, but that suggestion was seemingly dismissed.
“[Officers] noted similarities, but none of them thought they were the same person,” the report said.
Police contacted the woman’s accommodation service and emailed a photo of the girl. The report stated the officer had said the service staffer told them they were “confident” the girl in the photo was in fact “Person B”.
However, the staffer told the inquiry they “repeatedly told [the officer] they couldn’t be certain they were the same person”.
This then led to the officer informing hospital staff treating the girl that there had been a “potential identification” and provided the woman’s details, which then prompted the girl to be detained at Waikato Hospital because of the woman’s medical history.
The inquiry described the police actions as a “significant contributing factor” in misidentifying the girl because the officer didn’t convey the doubts of fellow officers about her identity.
“Police Officer 1 thereby gave an unbalanced impression of the reliability of this nomination and, further, did not provide any details that would have allowed hospital staff to conduct any independent checks.”
The girl was then given “intramuscular medication under restraint” without her consent, which was deemed in line with Person B’s medical history.
However, the inquiry found the injections were administered “without lawful authority”, because they had been given more than a month after the compulsory treatment order was made and without a second opinion as required under the Mental Health Act.
It wasn’t until after the injections that the girl was correctly identified and reunited with her mother.
Both Health NZ and Ministry of Health mental health director Dr John Crawshaw have apologised over the incident and committed to address the inquiry’s recommendations.
Adam Pearse is the Deputy Political Editor and part of the NZ Herald’s Press Gallery team based at Parliament in Wellington. He has worked for NZME since 2018, reporting for the Northern Advocate in Whangārei and the Herald in Auckland.