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Report on an unannounced inspection of Haumietiketike Unit, Rātonga-Rua-O-Porirua Campus, under the Crimes of Torture Act 1989

Issue date:

Executive summary


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 clients[1] detained in secure units within New Zealand hospitals.

Between 14 and 16 July 2020, two Inspectors[2] — whom I have authorised to carry out visits to places of detention under COTA on my behalf — made an unannounced inspection of Haumietiketike Unit (the Unit), which is located in the grounds of Rātonga-Rua-O-Porirua Mental Health Campus, Porirua. A focused follow up inspection was also carried out on 10 February 2021.   

Summary of findings

My findings are:

  • Files contained the necessary paperwork to detain and treat the clients on the Unit.
  • Clients spoken with felt safe and confirmed that they were treated with dignity and respect.
  • The Unit’s Morning Hui was a positive initiative.
  • Clients’ access to leave was well utilised and supported by Unit staff.
  • The Unit was clean and tidy.
  • Clients had good access to primary health care services.
  • Leadership on the Unit was visible.
  • Clinical supervision was actively promoted on the Unit and staff were supported to attend.
  • The orientation package provided to new staff and student nurses was comprehensive.
  • The recently introduced Positive Behaviour Support (PBS) training[3] for staff was well supported by the Unit leadership team.

The issues that needed addressing are:

  • The client previously identified as living in a seclusion[4] room on a permanent basis (in 2014[5] and 2018[6]) had not had a change to their living arrangements at the time of the inspection. A follow-up inspection saw a change in accommodation. During both inspections, the conditions under which Client A was accommodated may have amounted to cruel and inhuman treatment, and a breach of Article 16 of the United Nations Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment (‘Convention against Torture’).[7]
  • Seclusion Room One was not fit for purpose.
  • New clients were being admitted into seclusion rooms.
  • Night safety procedures[8] were not being recorded as seclusion events and the Night Safety Plan (NSP) paperwork was often a duplicate of the previous plan.
  • The complaints process was not well advertised or easily accessible for clients.
  • The Health and Disability Service ‘Code of Health and Disability Services Consumers’ Rights’ posters on display were not all in an accessible format.
  • Clients did not routinely receive an up-to-date copy of their care plan.
  • Clients were subject to overly restrictive practices and blanket restrictions, including lack of independent access to drinking water, hot drinks, and fresh air.
  • Clients’ access to Unit activities, religious, and cultural support was limited.
  • Clients were not able to use a telephone to contact the District Inspectors (DIs), independent of staff.
  • A high proportion of medication errors occurred at the point of administration.
  • The Unit had a high and increasing rate of staff turnover.


I recommend that:

  1. As a matter of urgency, Client A is provided with daily access to fresh air, the ability to exercise, and the ability to have meaningful engagement with others. This is an amended repeat recommendation.
  2. Seclusion Room One is decommissioned urgently.
  3. Seclusion rooms are never used as bedrooms.
  4. The use of night safety procedures be recorded, reported and treated as seclusion events.
  5. Complaint forms are available to clients at all times and the complaint process allows clients to make a complaint independent of staff.
  6. Copies of the Health and Disability Commissioner’s Code of Health and Disability Services Consumers’ Rights in Easy Read format should be available throughout the Unit. This is a repeat recommendation.
  7. Clients should receive an up-to-date copy of their care plan. This is a repeat recommendation.
  8. Clients have, at a minimum, independent access to drinking water. This is an amended repeat recommendation.
  9. All clients need to be offered daily access to fresh air. This should be documented, including when they decline. This is a repeat recommendation.
  10. Clients are provided more opportunities to engage in activities on the Unit. This is an amended repeat recommendation.
  11. Clients are provided more opportunities to engage with cultural and religious services. This is an amended repeat recommendation.
  12. Clients are able to make a complaint, and contact the DIs using a telephone, independent of staff. This is an amended repeat recommendation.
  13. The reasons for the number of medication errors at the point of administration are analysed and, where necessary, appropriate remedial action be implemented.
  14. The Unit regularly monitor and analyse the reasons for staff turnover and take action to address any concerning trends.

I intend to monitor the implementation of my recommendations, including conducting follow-up inspections at future dates.

Feedback meeting

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

District Health Board response

The Capital and Coast District Health Board (the DHB) received a copy of my provisional report and were invited to comment. The DHB responded and I have had regard to that feedback when preparing my final report.

The DHB’s letter and comments responded to a number of common themes from my inspections of the Unit and three other units in the DHB which were conducted at the same time[9], in particular around the use of seclusion rooms as bedrooms and ongoing reliance on night safety procedures (NSPs).

The DHB emphasised that they considered the reports provided evidence of unmet need within the forensic mental health services. The DHB noted the legal requirement to admit from court and the high acuity of the prison waitlist are such that the bed capacity in the forensic mental health service is continually exceeded. Many of the DHB’s responses to the recommendations also highlight significant financial pressure on the DHB and indicate the need for additional funding to achieve the recommendations. While I acknowledge that funding may be a barrier, my role as an NPM is to report on the conditions and treatment for people who are being detained, as they are at the time of the inspection. I intend to highlight my concerns with the Ministry of Health.

I also intend to conduct follow up inspections of all the Units, at which point I will be able to assess whether action to address my concerns has been implemented.


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

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

[3]     Delivered by Explore, the PBS framework ‘focuses on understanding a person’s needs and supporting them and the people around them to experience a better quality of life’ while reducing challenging behaviour. See for more information.

[4]     Seclusion is defined as: ‘where a person is placed alone in a room or area, at any time and for any duration, from which they cannot freely exit.’ Ministry of Health. Seclusion under the Mental Health (Compulsory Assessment and Treatment) Act 1992. Ministry of Health, Wellington, 2010.

[5]     Report on an announced visit to Capital and Coast District Health Board’s Haumietiketike Unit under the Crimes of Torture Act 1989. January 2014.

[6]     Report on an unannounced visit to Haumietiketike Unit under the Crimes of Torture Act 1989. April 2018.

[7]     UN Convention against Torture, Article 16(1): ‘Each State Party shall undertake to prevent in any territory under its jurisdiction other acts of cruel, inhuman or degrading treatment or punishment which do not amount to torture as defined in article I, when such acts are committed by or at the instigation of or with the consent or acquiescence of a public official or other person acting in an official capacity. In particular, the obligations contained in articles 10, 11, 12 and 13 shall apply with the substitution for references to torture of references to other forms of cruel, inhuman or degrading treatment or punishment.’

[8]     Night safety procedures are defined as ‘the practice of locking a patient in their bedroom overnight for the purposes of safety. The practice has no therapeutic function and constitutes (at the very least) a form of environmental restraint. Ministry of Health. Night Safety Procedures: Transitional Guideline. Ministry of Health, Wellington, 2018.

[9]     The units inspected at the same time were Rangipapa, Pūrehurehu, and Tāwhirimātea.

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