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Report on an announced follow up inspection of Ward 6C, Dunedin Hospital

Peter Boshier
Issue date:


Ombudsmen are designated as one of the National Preventive Mechanisms (NPMs) under the Crimes of Torture Act 1989 (COTA), with responsibility for examining and monitoring the conditions and treatment of patients detained in secure units within New Zealand hospitals.

My role is to form an independent opinion as to the conditions and treatment in these places, report my observations and if necessary make recommendations for improvement.

On 6 and 7 September 2022, two Inspectors - whom I have authorised to carry out visits to places of detention under COTA on my behalf - made an announced two-day inspection of Ward 6C, Dunedin Hospital to follow up on recommendations made following my previous inspection in May 2021. It was undertaken when all of Aotearoa New Zealand was at the COVID-19 Protection Framework (traffic light) orange setting.

The follow up inspection focussed on progress in implementing the recommendations I made in 2021, and whether I consider those recommendations to have been achieved or not.


At the time of the follow up inspection, Ward 6C was located on the sixth floor of Dunedin Hospital, in the Te Whatu Ora – Health New Zealand Southern region. The Ward was a 12-bed secure mental health/psychogeriatric ward for older persons (tāngata whai ora [1]). However, staffing challenges during the COVID-19 pandemic meant bed capacity was limited to nine beds.

My May 2021 inspection resulted in my making six recommendations. The DHB accepted all of those recommendations.

As a result of my 2022 follow up inspection I consider that one of these recommendations was achieved, two were progressing but not yet achieved, and three were not achieved.

On the basis of my follow up inspection, I make eight recommendations. Of these, five are repeat or amended repeat recommendations from my 2021 inspection, and three are new recommendations.

Feedback process

Health New Zealand – Te Whatu Ora and the Ministry of Health received a copy of my provisional report and were invited to comment. I received responses from the Ministry of Health and Health New Zealand - Te Whatu Ora and I have considered their feedback when preparing my final report.

At the time of the original inspection in May 2021, the Ward was under the management of the Southern District Health Board (the DHB).

Throughout this report there are references to the DHB, as the responsible body at the time of the original inspection. However, where appropriate, recommendations are made to Te Whatu Ora Southern, as the responsible agency at the time of the follow up inspection.


[1] A person who uses mental health and addiction services. This term is often used interchangeably with consumer or client. Return to text

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