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Report on an unannounced inspection of the Fraser McDonald Unit, Auckland District Health Board, 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 detained in secure units within New Zealand hospitals.

From 21 to 25 June 2021 (inclusive), Inspectors[1]  — whom I have authorised to carry out visits to places of detention under COTA on my behalf — made an unannounced inspection of the Fraser McDonald Unit, which is located in the grounds of Auckland City Hospital.  

Initial feedback to Facility from the physical inspection

Inspectors provided initial feedback to the Facility immediately after the inspection. This feedback was:

  • staff treated patients with dignity and respect, and spoke about the patients in a respectful way;
  • interpreters were used in a timely way, as and when required;
  • a project was underway to provide access to te reo Māori interpretation and cultural services for patients;
  • the Unit proactively planned patient reintegration back into the community;
  • the Unit’s leadership made a positive contribution to the care of the patients through their culture of continuous improvement.

The issues that need addressing are:

  • there was no record indicating that voluntary patients or their authorised representatives[2] had consented to being in a secure unit;
  • there was no clear distinction between restrictions placed on patients who were admitted to the Unit on a voluntary basis and those who were admitted under the Mental Health (Compulsory Assessment and Treatment) Act 1992;
  • there was no anonymous way for patients and their whānau[3] to make a complaint.


I recommend that:

  1. The Unit works with the Auckland District Health Board to develop a policy and procedure to ensure voluntary patients are fully informed about what it means to be in a locked unit, and their informed consent to be in the Unit is sought and recorded.
  2. The Unit puts in place processes to enable voluntary patients to leave the Unit freely and safely, and informs voluntary patients and their whānau of these processes.
  3. The Unit ensures patients are provided with access to Māori cultural services, including experts in te reo Māori and tikanga Māori.


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 Auckland District Health Board and the Unit’s leadership team, to summarise their initial observations.


[1]     When the term Inspectors is used, it refers to the inspection team including the OPCAT Manager, Senior Inspectors, and Inspectors.

[2]     A patient’s authorised representative may be their Enduring Power of Attorney or Welfare Guardian.

[3]     This document refers to whānau rather than family. In Te Ao Māori, whānau encompasses family in the fullest meaning. Whānau may include immediate and extended family, whakapapa (genealogy), as well as all persons connected by emotional or spiritual bonds. Any person who has been involved in the care or welfare of a patient may also be considered whānau (kaupapa whānau).

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