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Report on an unannounced inspection of Puna Poipoi Forensic Rehabilitation 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 18 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 Poipoi Forensic Rehabilitation Ward (the Ward), which is located within the grounds of Waiora Waikato Hospital campus, Hamilton.  

Summary of findings

My findings are:

  • Interactions between staff and service users were respectful, constructive and appropriate.
  • Service users who spoke with Inspectors were positive about their experiences on the Ward.
  • Files contained the necessary paperwork to detain and treat the patients in the Unit.
  • Care plans were up-to-date, with evidence of regular reviews occurring.
  • The Multi-Disciplinary Team (MDT) reviews for service users were thorough. Service users were included in the MDT review and offered a copy of their review documentation.
  • The Ward was clean, tidy and well maintained.
  • Generally, service users described the meals as adequate.
  • There was evidence that service users regularly attend medical appointments, including dental appointments.
  • Staff who spoke with Inspectors were positive about the leadership and management of the Ward and felt supported.

The issues that needed addressing are:

  • There was no information on how to make a complaint or contact details for District Inspectors displayed on the Ward.
  • Service users’ toiletries were locked away and accessible only on request.
  • The Ward was not fit for purpose; bedrooms were small with inadequate storage and no ventilation, and there were insufficient numbers of showers and toilets for service users.
  • Service users were unable to access hot drinks independent of staff, and were not able to eat and drink their own food on the Ward.
  • There was no fresh air accessible to service users on the Ward other than in the courtyard, which was locked and could be accessed only with staff support and supervision.
  • Service users had limited access to programmes and activities, minimal community engagement, and restricted outings.
  • The visits room was not fit for purpose.
  • Service users were unable to access the telephone independent of staff.
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