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Report on an announced follow up inspection of Ward 9B Wakari Hospital, Dunedin

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.

From 26 to 30 September 2022, two Inspectors – whom I have authorised to carry out visits to places of detention under the COTA on my behalf – made an announced five-day inspection to Ward 9B at Wakari Hospital in Dunedin to follow up on recommendations made when I inspected in 2019. Therefore, the inspection is referred to as a ‘follow up inspection’.

The follow up inspection focussed on progress in implementing the recommendations I made as a result of my 2019 inspection, and whether I consider these recommendations to have been achieved or not.


Ward 9B is an adult mixed gender, inpatient ward for tāngata whai ora [1] experiencing acute mental health issues. It is a locked facility located in the grounds of Wakari Hospital.

My 2019 inspection resulted in me making 11 recommendations. The DHB accepted 10 of those recommendations and partially accepted one recommendation.

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

On the basis of my follow up inspection, I make eight recommendations. These are generally amended repeat recommendations from my 2019 inspection.

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 Te Whatu Ora Southern and the Ministry of Health, and I have considered their feedback when preparing my final report.

Throughout this report, there are references to the Southern District Health Board, as the responsible body at the time of the original inspection in 2019. However, where appropriate, recommendations are made to Health New Zealand - Te Whatu Ora, 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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