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Report on an announced targeted inspection of Ngā Rau Rākau, Hawke’s Bay Fallen Soldiers’ Memorial 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.

From 23 November 2021, a team of 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 to the Unit.

At the time of this inspection the region was operating at COVID-19 Alert Level 2. For this reason, the inspection was shorter and more focused than a full inspection, and this is why it is referred to as a ‘targeted inspection’.


Ngā Rau Rākau (the Unit) is a 23-bed, mixed-gender, intensive mental health inpatient unit, located in the grounds of Hawke’s Bay Fallen Soldiers’ Memorial Hospital. On the first day of inspection, the Unit was over occupancy, operating at 109 percent of its funded capacity.

As a result of my inspection, I made 5 recommendations to the Unit, 1 recommendation to Te Whatu Ora, 4 recommendations jointly to the Unit and Te Whatu Ora, and 1 recommendation to Manatū Hauora, the Ministry of Health.

Feedback process

At the time of inspection the Unit was owned and operated by the Hawke’s Bay District Health Board (the DHB).

Unit Management, the DHB and the Ministry of Health received a copy of my provisional report and were invited to comment. Health New Zealand - Te Whatu Ora was subsequently invited to do the same. I received responses from the Unit – who responded on behalf of themselves and the DHB, the Ministry of Health and Health New Zealand - Te Whatu Ora. I have considered their feedback in finalising this report. I am grateful for the time taken to consider my provisional report.

At the time of this inspection, the Unit was under the management of the Hawkes Bay District Health Board (the DHB). Throughout this report there are references to the DHB, as the responsible body at the time of the inspection. However, Te Whatu Ora’s feedback was also sought and, where appropriate, recommendations are made to Te Whatu Ora, as the responsible agency at the time of finalising this report.

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