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Report on an announced inspection of Manaakitanga Inpatient Unit, Te Nīkau Grey Base Hospital, under the Crimes of Torture Act 1989

Issue date:

Executive summary


Ombudsmen are designated 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[1] detained in secure units within New Zealand hospitals.

Between 20 and 23 April 2021, two inspectors[2], whom I have authorised to carry out visits to places of detention under COTA on my behalf, made an announced inspection of Manaakitanga Inpatient Unit (the Unit), which is located in the grounds of Te Nīkau Grey Base Hospital, Greymouth.

Patients receive acute mental health services provided by West Coast District Health Board’s (DHB’s) Adult Mental Health Services (the Service).

Summary of findings

My findings are:

  • There was no evidence that any patient had been subject to torture or other cruel, inhuman or degrading treatment or punishment.
  • The Unit had devoted significant time and energy to reducing the levels of seclusion, and staff in the Unit appeared to be genuinely committed to Zero Seclusion.
  • The Unit recorded every instance of locked doors as environmental restraint. Processes for implementing and recording environmental restraint were robust.
  • The Unit’s response to the complaint received in the reporting period was thorough, personalised, and addressed the concern raised.
  • Files contained the necessary paperwork to detain and treat patients on the Unit.
  • The Unit had robust procedures to ensure voluntary patients could enter and exit the Unit at will.
  • The Unit was generally clean, tidy and well maintained. The Unit had new furnishings, which was a positive development since my predecessor’s previous inspection in 2015.[3]
  • The Unit had an Occupational Therapist (OT) who was responsible for the wellbeing programme which provided structured daily activities. Staff were complimentary of the work done by the OT to increase the activities available to patients on the Unit.
  • Cultural and spiritual support was available for patients on the Unit.
  • Patients were able to keep and use their cell phones, unless there was a specific reason not to.
  • Staffing numbers had increased. Staff said they felt safe and were positive about the leadership of the Unit.

The issues that need addressing are:

  • The seclusion area was stark and blinds in the seclusion room could not be independently controlled by patients.
  • In the six months prior to the inspection, a patient under the age of 18 was secluded. There was not clear evidence of robust processes to ensure that young people were secluded only as a last resort where all other methods have been exhausted and failed.
  • Security personnel had been involved in several restraint events in the reporting period, including where medication had been administered through intramuscular injection (IMI).
  • The needs of female patients did not appear to be met by the involvement of male security personnel in seclusion and restraint events.
  • Approximately half of the staff were out-of-date with their Safe Practice Effective Communication (SPEC) training[4] at the time of the inspection.
  • There was no information about the Complaints Procedure on display on the Unit.
  • Consent paperwork for voluntary patients was not always fully completed.
  • The paperwork for voluntary patients indicated leave restrictions were placed on voluntary patients.
  • Patients and their whānau were not invited to their multi-disciplinary team (MDT) meetings.
  • The Unit was not purpose built for its function as an acute mental health inpatient unit. This meant, among other things, there was a lack of appropriate spaces to accommodate different groups of people.
  • The low stimulus area was not fit for purpose as a bedroom.
  • The potential for patients to share double rooms was inappropriate.
  • There was scope to further incorporate tikanga Māori and cultural support in the Unit’s day-to-day operations.
  • There was a no process for consultation with other patients when whānau were to stay on the Unit. 
  • The lock was not functioning on one of the medication cupboards, where another part of the mental health service was storing controlled medications.


I recommend that:

  1. The DHB upgrade the seclusion area, in particular to ensure the environment is more therapeutic and supports patients’ privacy, dignity and mana.

  2. Restraint paperwork is completed for all restraint events.

  3. The Unit establishes robust processes to ensure that young people are only secluded as a last resort, where all other methods have been exhausted and failed.

  4. Patients’ dignity and mana is upheld during restraint by ensuring only appropriately trained staff are involved and by using a trauma-informed approach to restraint.

  5. All staff remain up-to-date with SPEC training.

  6. The complaints process is well advertised and accessible on the Unit.

  7. Voluntary patients’ informed consent is routinely sought and recorded.

  8. Leave restrictions are not placed on voluntary patients.

  9. Patients and their whānau are invited to their MDT wherever possible, and are routinely kept informed of the outcome of their meetings.

  10. The Unit is upgraded to ensure that there is appropriate accommodation available for all patients.

  11. The low stimulus room is not used as a bedroom.

  12. Double rooms are not used to accommodate more than one patient.

  13. Patients have regular access to therapeutic programmes.

  14. The Unit further incorporates tikanga Māori and cultural support in the Unit’s day-to-day operations, for example by including te ao Māori perspectives in MDT meetings.

  15. The Unit establishes processes to consult with other patients when whānau are to stay on the Unit.

  16. All medication is securely stored.


Follow up inspections will be made at future dates to monitor implementation of my recommendations.

Feedback meeting

On completion of the inspection my Inspectors met with representatives of the Unit’s multi-disciplinary team to outline their initial observations.


The West Coast District Health Board (DHB) and the Ministry of Health received a copy of my provisional report and were invited to comment. The DHB Mental Health Service and the Ministry of Health responded and I have had regard to that feedback when preparing my final report. I am grateful to the DHB Mental Health Service and the Ministry for their input, which has contributed positively to my final report.


[1]     Patients was the term used by the Unit to describe people using mental health and addiction services. This term is often used interchangeably with consumer, client, service user and/or tāngata whai ora.

[2]     When the term Inspectors is used, this refers to the inspection team comprising a Senior Inspector and an Assistant Inspector.

[3]     Office of the Ombudsman report on an unannounced inspection to Manaakitanga Mental Health Inpatient Unit under the Crimes of Torture Act 1989, September 2015.

[4]     SPEC training was designed to support staff working within inpatient mental health wards to reduce the incidence of restraints. SPEC training has a strong emphasis on prevention and therapeutic communication skills and strategies, alongside the provision of training in safe and pain free personal restraint techniques.

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