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Media release

Chief Ombudsman critical of overcrowding at Henry Bennett

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The Chief Ombudsman is calling on the Waikato District Health Board to address overcrowding, and the high use of seclusion and physical restraints, at its Henry Rongomau Bennett Centre.

“I consider there is an urgent need to deal with the issues I have raised.”

This is the first time he has released his reports into the conditions and treatment of people held in New Zealand’s public health and disability facilities. All reports on public health and disability facilities will be considered for publication in the future.  

Mr Boshier today tabled his four reports in Parliament on the Hamilton mental health facility, following unannounced inspections in September 2019.

The inspections focussed on Wards 34, 35, 36, and the Awhi-rua, Puna Maatai and Puna Poipoi wards which provide a range of sub-acute, acute, forensic, and rehabilitative, inpatient mental health services for 88 adults from the Waikato, Lakes, Taranaki, and Bay of Plenty regions.

Mr Boshier says he is aware the government has announced funding of $100 million to replace the Henry Rongomau Bennett Centre and that the new facility is due to open in 2023.

“In the meantime, the treatment and conditions of service users in three out of the four wards I inspected was degrading and the result of overcrowding. It breached Article 16 of the United Nations Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment.

“I believe the current situation at the acute mental health service (Wards 34, 35, 36) is untenable. At the time of inspection, the three wards were at 130 percent capacity.

“Inappropriate placements of service users, high use of seclusion and restraint, lack of privacy, blanket restrictions, compromised care, and limited opportunity for recovery are indicators of a facility in crisis.”

In Puna Maatai Forensic Inpatient Ward, there had been a significant increase in the use of seclusion in recent years, particularly for Māori service users.

“There were discrepancies in the collection and reporting of seclusion and restraint data, training on the use of mechanical restraints did not appear to comply with policy, and the relevant restraint policies themselves were out of date.

“I consider that the ward should guard against treating the use of mechanical restraint as normal practice by regularly monitoring and reviewing its use.”

In Puna Awhi-rua, my Inspectors found evidence of a service user placed in seclusion for 16 weeks following an assault on a staff member. The records however did not support the prolonged period of seclusion and, in these circumstances, was degrading treatment.

Mr Boshier is also concerned at the regular use of a practice described by staff as ‘sleepovers’. This is where people were transferred from one ward to another to relieve pressure on staffing or space.

Inspectors observed service users on sleepovers in wards for days at a time because acute wards were too full. They saw communal areas, day rooms and offices being used as bedrooms. “Installing curtains and partial walls in the shared bedrooms of Wards 34, 35, and 36, did not provide enough privacy, and service users also reported not feeling safe,” says Mr Boshier.

Staff burnout is also a concern on Puna Maatai, due to over-crowding, lack of resources, and the high and complex needs of service users from the courts and prisons, and service users with intellectual disabilities.

Mr Boshier says there are plans to address overcrowding, and reduce the use of seclusion and restraint. “However, I’ve had to repeat recommendations made during earlier inspections which is of concern.”

While other wards were generally clean and tidy, he says the Puna Poipoi Forensic Rehabilitation Ward was not fit-for-purpose: bedrooms were small with inadequate storage and no ventilation, and there weren’t enough showers and toilets.

“While I am pleased to hear that the DHB is taking steps to address a number of identified issues, my role is to report on the conditions and treatment for people who are being detained, as they were at the time of the inspection.”



Mark Torley, Manager Communications, 027 275 5733

More information

The Chief Ombudsman has been inspecting secure units in health and disability facilities since 2008. He reports on what his Inspectors see at the time of the inspection, to the facility, and the relevant District Health Board. His reports highlight good practice, identify areas for improvement, and make recommendations where necessary. All facilities, and their DHB, are provided with the opportunity to comment on his provisional opinion and recommendations before he finalises his report.

He will be publishing future health and disability inspection reports on a case-by-case basis, where he considers this will further the preventive focus of his interventions. He will not be publishing reports of previous health and disability inspections.

The Chief Ombudsman has been publishing his prison reports since 2017, and has seen increased uptake of his recommendations to make improvements to prisons since then. In 2018/19 for example, he made a total of 122 recommendations and all but 7 were accepted.

More information about the Chief Ombudsman’s inspections is available from:

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