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Report on an unannounced inspection of Puna Maatai 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 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 five day inspection of the Puna Maatai 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 that service users were subject to degrading treatment.
  • All service users had the necessary legal documentation to be detained in the Ward.
  • The Ward was clean, tidy and well-maintained.
  • There were adequate bathroom, shower and laundry facilities for the number of service users.
  • Staff appeared to work together collegially and effectively and spoke positively about the support provided by the management team.
  • Interactions between staff and service users were respectful, constructive and appropriate.
  • Whānau spoken with by Inspectors did not report any issues about service users’ access to visitors.
  • There was robust multi-disciplinary team work occurring regarding the ongoing care of service users, including the exploration of various treatment approaches.
  • Cultural and spiritual support was provided on the Ward.

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.
  • Not all staff had the necessary knowledge and skills to deal with a diverse service user group.
  • Insufficient natural light in the seclusion room and an inability for service users in seclusion to maintain orientation to date and time.
  • The significant increase in the use of seclusion in recent years, and in particular the high levels of seclusion of Māori service users.
  • Discrepancies in the collection and reporting of seclusion and restraint data.
  • Relevant restraint policies were out of date at the time of the inspection.
  • Training in the application of mechanical restraints on the Ward did not appear to comply with the policy on their use.
  • Contact details for District Inspectors were not visible on the Ward.
  • Consent to treatment forms were absent or out of date for most service users at the time of the inspection.
  • Service users were unable to leave the dining area when they were ready to do so, or access hot drinks independent of staff.
  • A lack of purposeful activities for service users in the afternoons and limited access to therapeutic programmes.
  • Service users were unable to access the telephone independent of staff and generally only between 6pm and 9pm.
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