Serious failures at adult intellectual disability inpatient ward in Dunedin highlight need for strengthened commitment from health agencies
The Chief Ombudsman says the serious issues identified at Wakari Hospital’s Ward 10A highlight the urgent need for agencies to show greater commitment to the safety and dignity of the most vulnerable people in their care.
John Allen called on Health New Zealand and the Ministry of Health to act immediately after a team of Ombudsman inspectors visited Ward 10A — an inpatient forensic unit for adults with intellectual disabilities — in March this year.
“I am disturbed by what our inspectors found. What they observed at Ward 10A are some of the worst practices we have observed anywhere,” says Mr Allen.
“We found compelling evidence of punitive and coercive treatment of people in the ward. Some were subjected to prolonged environmental restraint and/or long-term seclusion.
“In one instance, a person was being tied down on a bariatric or ‘EVAC’ mat to move them around the ward. This was causing physical and mental harm to the person who suffered carpet burns as a result.
“Inspectors also found that one person had been secluded in their bedroom for around 18 months with an almost complete lack of meaningful human contact and no access to the outdoors.
“Other instances of ill-treatment included restrictions on dental care and people being denied access to their own money. Staff were observed incentivising ‘good’ behaviour by rewarding people with access to basic necessities including dental treatment or the use of a toilet.
“Inspectors also noted that treatment of people may have extended to the unlawful administration of medication.
“These are allegations of serious and significant failures that amount to potential human rights abuses. This punitive and coercive approach to the care of people in Ward 10A is unacceptable.
“It is also very concerning that there has been next to no improvement to the physical structure of Ward 10A despite ongoing concerns. Infrastructure, facilities and the physical environment must be fit-for-purpose. This is critical to the health, safety and well-being of people in the ward and for staff. This applies not just to Ward 10A but across the system.”
The inspection, between 17 and 20 March 2026, was carried out under the Crimes of Torture Act 1989. It was part of the Ombudsman’s role under the Optional Protocol to the Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment (OPCAT).
“We chose to raise our concerns directly with the Ministry of Health and Health NZ. They have both acknowledged our concerns and the importance of ensuring that all people in Ward 10A are treated properly,” Mr Allen says.
“The Ministry of Health has accepted my recommendation to undertake an independent investigation into the treatment and conditions of people at Ward 10A and have closed the ward to new admissions. It is very important now that they make sure the same number of beds are available across the structure to avoid putting more pressure on the system.
“Health New Zealand says they have taken these matters very seriously. I will be closely monitoring the progress and actions taken by both Health New Zealand and the Ministry of Health.
“The issues at Ward 10A are a stark reminder that much more needs to be done to make sure the very vulnerable in our community, like people with intellectual disabilities, are kept safe and treated with dignity and respect. This requires a sustained approach and acknowledgment that a one-size-fits all approach will not work.
“New Zealand has an obligation under international and domestic law to ensure people are not subjected to ill-treatment as well as a positive duty to investigate where there are reasonable grounds to believe that ill-treatment has occurred.”
Mr Allen says the inspections at Ward 10A are an example of a critical function performed by his office.
“While we don’t want to find and uncover situations like this, when we do, this is how we respond. I am very grateful for the work of our inspectors.”