Open main menu Close main menu

Report on an unannounced follow up inspection of Te Toki Maurere Unit, Whakatāne Hospital, under the Crimes of Torture Act 1989

Issue date:

Executive Summary


This report sets out my findings and recommendations concerning the treatment and conditions of people detained in Te Toki Maurere Acute Mental Health Inpatient Unit (the Unit), which was inspected between 26 and 28 July 2021. The Unit is located on the Whakatāne Hospital Campus, Whakatāne.

In the Unit, clients [1] receive acute mental health services provided by the Bay of Plenty District Health Board’s (DHB’s) Mental Health and Addictions Service (the Service).

This report has been prepared in my capacity as a National Preventive Mechanism (NPM) under the Crimes of Torture Act 1989 (COTA). Ombudsmen are designated as one of the NPMs under the COTA, with responsibility for examining and monitoring the conditions and treatment of detained people in the relevant places of detention. My responsibility includes hospital units in which people are detained.

This report examines the Unit’s progress implementing the 13 recommendations I made in 2018. It also includes findings on the conditions and treatment of clients detained in the Unit at the time of my follow up inspection on 26 – 28 July 2021, resulting in 10 recommendations.

I found that five of the 13 recommendations I made in 2018 had been achieved, one had been partially achieved, and seven had not been achieved.

Overall, during the follow up inspection I found that:

  • Procedures were in place to facilitate clients’ access to the Sensory Modulation Room.
  • All voluntary clients had signed consent to treatment paperwork on file.
  • The Unit was clean and tidy.
  • Access to whānau and visits was evident and strongly encouraged.
  • The past high number of medication errors had been addressed.
  • High staff turnover had been addressed.
  • Client and staff interactions were positive and staff knew their clients well.
  • Staff were regularly seen engaging with clients in a professional and respectful manner.
  • Senior management was clearly visible, supportive, and engaged on the Unit.
  • Kaupapa Māori practices and tikanga were well embedded on the Unit and underpinned operational practice.
  • Staff demonstrated good de-escalation skills and Inspectors observed a room entry and planned restraint which were conducted in a calm and professional manner.

The issues that need addressing are:

  • The building was not fit-for-purpose and, despite multiple and repeat recommendations in previous OPCAT reports, a number of ongoing issues had not been addressed, including:
    • The seclusion facility, including the de-escalation and seclusion room, and low stimulus area, did not provide for therapeutic care;
    • Accommodation facilities did not provide gender separation to ensure privacy and safety needs were met; and
    • Communal areas and bathroom facilities did not meet the needs of clients for comfort, privacy and personal hygiene.
  • Data recording systems had not been improved to ensure the reliability and accuracy of seclusion information.
  • Not all staff were up-to-date with Safe Practice Effective Communication (SPEC) training requirements.
  • The Unit was regularly over occupancy, which was impacting on the safe management of the Unit.
  • The Unit was not recording environmental restraint [2] when the front door to the Unit was locked, nor when access to the main bedroom wing was restricted.
  • Information was not available or displayed on the Unit to ensure that voluntary clients were fully informed of their right to leave the Unit at will.
  • Arrangements had not been implemented to ensure clients understood the complaints process.
  • Treatment plans were not always signed by clients, or, where appropriate, countersigned by staff.
  • While some purposeful activity was provided on the Unit, there was no formal activities programme due to an ongoing Occupational Therapist vacancy.
  • Information about visiting hours was inconsistent.

As a result of my follow up inspection, I make 10 recommendations to improve the conditions and treatment of the Unit’s clients. Disappointingly, five of these are repeat recommendations.

I will be assessing the Unit’s progress in implementing the recommendations in this report in the future.

I wish to express my appreciation to the Clinical Nurse Manager, clients and staff of the Unit for the full co-operation they extended to my Inspectors. I also acknowledge the work involved in collating the information they requested.


As a result of my 2021 follow up inspection, I recommend:

Treatment of clients

  1. The Unit improves data recording systems to ensure the reliability and accuracy of seclusion information collected and reported. This is an amended repeat recommendation.
  2. The Unit ensures all appropriate staff remain up-to-date with Safe Practice Effective Communication (SPEC) refresher training.
  3. The DHB addresses the issue of over occupancy as a matter of urgency.
  4. The Unit records and reports all instances of environmental restraint.
  5. The Unit ensures voluntary clients are fully informed of their right to enter and exit the Unit, and how to do so.
  6. The Unit implements arrangements to ensure clients understand the complaints process. This is an amended repeat recommendation.
  7. The Unit ensures all treatment plans are signed by the client, or, where appropriate, countersigned by a member of staff to indicate that the client has declined to sign the form or is unable to do so. This is a repeat recommendation.
  8. The DHB urgently progresses the rebuild in line with best practice for the design of mental health facilities.
  9. The Unit increases the amount of leisure/purposeful activities available to clients. This is an amended repeat recommendation from two previous inspections.
  10. The Unit ensures that formal visiting hours are consistently referred to in all information available to clients and visitors. This is an amended repeat recommendation.


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

[2] Environmental restraint is where a service provider(s) intentionally restricts a service user’s normal access to their environment, for example where a service user’s normal access to their environment is intentionally restricted by locking devices on doors or by having their normal means of independent mobility (such as wheelchair) denied. Health and Disability Services (Restraint Minimisation and Safe Practice) Standards. Ministry of Health. 2008. Return to text

Last updated: