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Report on an unannounced inspection of Puna Awhi-rua Forensic Inpatient Ward, Waikato Hospital, under the Crimes of Torture Act 1989

Peter Boshier
Issue date:


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 detained in secure units within New Zealand hospitals.

Between 16 September and 20 September 2019, Inspectors — whom I have authorised to carry out visits to places of detention under COTA on my behalf — made an unannounced inspection of Puna Awhi-rua Forensic Inpatient Ward (the Ward), which is located in the grounds of Waiora Waikato Hospital campus, Hamilton.

Summary of findings

My findings are:

  • There was no evidence that any service user had been subject to torture or other cruel, or inhuman treatment or punishment. However, my Inspectors found evidence of a service user subject to degrading treatment.
  • All service users had the necessary legal documentation to be detained in the Ward.
  • Consent to treatment forms were on file for all service users.
  • All service users’ paperwork was up to date and well maintained.
  • The multi-disciplinary team (MDT) reviews and START meetings for service users were thorough and the service users were included in the MDT review and offered a copy of their review documentation.
  • Interactions between staff and service users were respectful, constructive and appropriate.
  • Staff who spoke with Inspectors were positive about the leadership on the Ward and felt supported.
  • Service users who spoke with Inspectors were positive about their experiences on the Ward.
  • The Ward was clean, tidy and well maintained.
  • Service users had their own bedroom that they could lock.
  • The Ward had a separate accommodation area for women service users.
  • There were adequate bathroom, shower and laundry facilities for the number of service users.
  • Cultural and spiritual support was provided on the Ward.
  • Staff retention had improved.

The issues that needed addressing are:

  • The accommodation of service users in rooms other than designated bedrooms amounted to degrading 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’).
  • Some staff reported they did not have the necessary knowledge and skills to deal with the diverse service user group.
  • A prolonged seclusion that did not adhere to Seclusion Procedure.
  • Lack of privacy blinds in the seclusion/high care secure lounge.
  • The inability for service users in seclusion to maintain orientation to day and time.
  • Discrepancies in the collection and reporting of seclusion data.
  • Relevant restraint policies were out-of-date at the time of the inspection.
  • Discrepancies in the collection and reporting of restraint data, including service users’ ethnicity.
  • No induction/information packs were given to service users or whānau.
  • Complaint forms were not available on the Ward on the first day of inspection.
  • Contact details for District Inspectors were not displayed on the Ward.
  • Service users’ recovery plans were not signed.
  • Service users’ bedroom door observation panels afforded little privacy.
  • Service users were subject to a restrictive bedroom access regime.
  • Service users were unable to access hot drinks and personal food items independent of staff.
  • Service users had limited access to leisure activities.
  • Service users were unable to access the telephone independent of staff and generally only between 6pm and 9pm.
  • Admission checklists were not in place.
  • Staff vacancies in key positions.
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