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Report on an announced targeted inspection of Te Whare Awhiora, Gisborne 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 27 October 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 of Te Whare Awhiora, Gisborne Hospital. At the time of this inspection, Gisborne was 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’.


Te Whare Awhiora is based at Ward 11, Gisborne Hospital. It is an eight-bed, mixed-gender, acute, inpatient mental health unit.

As a result of my inspection, I made 14 recommendations to the ward, 1 recommendation to Te Whatu Ora, and 3 recommendations jointly to the Ward and Te Whatu Ora.

Feedback process

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

At the time of inspection, the unit was owned and operated by the Hauora Tairāwhiti 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, where appropriate, recommendations are made to Te Whatu Ora, as the responsible agency at the time of finalising this report.

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