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Report on an unannounced inspection of He Puna Wāiora Mental Health Inpatient Unit, North Shore Hospital, under the Crimes of Torture Act 1989

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Executive Summary


In 2007, the Ombudsmen were 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 service users[1] detained in secure units within New Zealand hospitals.

Between 19 November and 22 November 2019, Inspectors[2]  — whom I have authorised to carry out visits to places of detention under COTA on my behalf — made an unannounced inspection of He Puna Wāiora Mental Health Inpatient Unit (the Unit), which is located in the grounds of North Shore Hospital Campus, Auckland.

Summary of findings

My findings are:

  • There was no evidence that service users had been subject to torture or other cruel, inhuman or degrading treatment or punishment.
  • The Unit had a robust process for recording who has been offered use of sensory modulation,[3] and what service users’ sensory preferences were.
  • Service user and whānau views on the Unit were generally positive.
  • Up-to-date contact details for District Inspectors (DIs) were visible in each of the wards and the DIs had an active presence on the Unit.
  • Files contained all the necessary paperwork to detain and treat service users on the Unit.
  • Consent to treatment forms were available for most, but not all, service users subject to a compulsory treatment order.
  • Court sittings are regularly scheduled and service users’ have access to legal representation.
  • The Unit was generally clean, tidy and well maintained.
  • Service users had free access to the courtyards and fresh air throughout the day.
  • Service users had their own bedrooms and a unique electronic bracelet to unlock the door to their room.
  • The Unit offered activities and programmes during the week, after hours and in the weekend.
  • The Unit had relationships with a range of cultural services and employed a Cultural Advisor on the Unit.
  • Inspectors observed whānau visiting service users regularly and noted that staff treated whānau with respect.
  • Service users’ had access to primary health care services.

The issues that needed addressing are:

  • Service users in seclusion were provided with a cardboard receptacle in which to urinate or defecate. Inspectors noted the receptacle was visible from the seclusion door window and the observation room, which posed a serious risk to service users’ privacy and dignity.
  • There was an unpleasant musty odour in the seclusion room, reportedly due to problems with the pipes.
  • Seclusion paperwork had inconsistent levels of detail and was often incomplete.
  • The District Health Board’s (DHB) Door Locking: Egress of Adult Inpatient Unit Doors Policy was out-of-date and needed to be updated to accurately reflect the status of voluntary service users.[4]
  • Leave restrictions and the lack of information detailing the process for entry and exit into the Unit had the potential to arbitrarily detain voluntary service users.
  • There was no information about the complaints process on display on the Unit, including on the role of the DIs.
  • Service users were not invited to their Multi-Disciplinary Team (MDT) meetings and did not regularly receive feedback on the outcomes of these meetings.
  • The courtyards in the High Care Areas required cleaning due to birds roosting in the area.
  • The removal of the en-suite doors had a significant impact on service users’ privacy and dignity.
  • There was more demand for cultural competency, support, guidance and facilities than the Unit currently provided.
  • Tāngata whai ora[5] were transferred to other facilities at short notice and without involvement of cultural support.
  • If service users did not have a cell phone, they were dependent on staff to provide access to a portable phone.
  • Staff morale on the Unit was extremely low and there had been very high turnover over the past three years (the period for which information regarding staff turnover was requested).


I recommend that:

  1. Measures are taken to ensure that service users in seclusion cannot be viewed when urinating or defecating.
  2. The toilet in the de-escalation area be accessible by service users in seclusion, unless this would pose a serious risk of harm to the service user or staff. If an individual service user is not allowed to access the toilet, the reasons are recorded and reviewed.
  3. Measures are taken to eliminate the unpleasant musty odour in the seclusion area.
  4. All seclusion paperwork is fully and accurately completed.
  5. The Door Locking: Egress of Adult Inpatient Unit Doors Policy be reviewed, and updated to accurately reflect the status of voluntary service users.
  6. The Unit address the risk of arbitrarily detaining voluntary service users by prominently displaying the process for entry and exit into the Unit, including in the Unit entrance. This is an amended repeat recommendation.
  7. Information on the complaints process should be easily visible and accessible to all service users, including information on the role of the District Inspectors. This is an amended repeat recommendation.
  8. Service users be invited to attend their Multi-Disciplinary Team meeting, wherever possible, and routinely informed of the outcome of their review. This is an amended repeat recommendation.
  9. The High Care Area courtyards are cleaned regularly.
  10. The replacement of en-suite doors with ‘stable doors’, or a suitable safe alternative, takes place as a matter of priority to ensure service users’ privacy.
  11. The level of cultural support on the Unit be increased and appropriate spaces are designated to welcome tāngata whai ora and staff with a pōwhiri or mihi whakatau.
  12. The garage is not used as an entrance to the Unit unless other options are deemed unsafe based on individual risk assessment.
  13. Cultural advice informs decisions on transferring or discharging tāngata whai ora.
  14. Service users have access to a telephone, independent of staff, unless deemed unsafe based on individual risk assessment.
  15. The Unit takes action to rebuild staff morale and address the high turnover rate.

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 Unit’s leadership team, to outline their initial observations.


A provisional report was forwarded to the DHB for comment as to fact, finding or omission prior to finalisation and distribution.


[1]     A person who uses mental health and addiction services. This term is often used interchangeably with consumer and/or tāngata whai ora. See  Mental Health Foundation website,

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

[3]     ‘Sensory modulation uses a range of tools to help individuals get the right amount of sensory input. In mental health settings, sensory modulation can be used to assist distressed service users to regain a sense of calm’. Te Pou o te Whakaaro Nui (2011). Sensory modulation in inpatient mental health: A summary of the evidence. Auckland. Te Pou o Te Whakaaro Nui.

[4]     ‘Voluntary’ means that the service user has agreed to have treatment and has the right to suspend that treatment. If the service user is being treated in hospital, they have the right to leave at any time.

[5]     People with experience of mental illness, who are seeking wellness, or recovery of self. Usually used in reference to Māori service users.  See Mental Health Foundation website,

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