Open main menu Close main menu

Report on an unannounced inspection of Pūrehurehu Forensic Acute Mental Health 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 patients detained in secure units within New Zealand hospitals.

Between 14 and 16 July 2020, two Inspectors[1] — whom I have authorised to carry out visits to places of detention under COTA on my behalf — made an unannounced three day inspection of Pūrehurehu Forensic Acute Mental Health Inpatient Unit (the Unit), which is located in the grounds of Rātonga-Rua-O-Porirua Mental Health Campus, Porirua.

Summary of findings

My findings are:

  • There was no evidence that any patient had been subject to torture or other cruel or inhuman treatment or punishment.
  • Inspectors saw positive and respectful interactions between staff and patients.
  • The use of restraint was low.
  • Patients and whānau spoken with were complimentary about their experiences on the Unit.
  • District Inspectors’ (DI) contact details were well displayed on the Unit.
  • Patients in the Rehabilitation Wing[2] had been supported to develop their own Rehabilitation Wing guidelines to outline expectations to achieve positive interactions and respectful behaviour on the wing.
  • Patients were invited to attend their Multi-Disciplinary Team meetings (known as Huihui), were given a copy of Huihui documentation prior to the meetings, and were provided with feedback of the outcomes of these meetings.
  • A new intensive psychiatric care (IPC) wing, called Tanerore, had been built.
  • The Unit was clean and tidy.
  • There were no complaints about the quality or quantity of the food.
  • There was a wide range of activities and programmes available to patients.
  • Communication and access to visitors was good. Whānau from out of region were given practical support to visit where possible.
  • There was evidence that patients were regularly attending their medical appointments.
  • Unit staff and patients spoken with generally felt safe on the Unit, and staff spoken with felt well-supported by colleagues and Unit management.

The issues that needed addressing are:

  • The seclusion[3] room was being used as a bedroom, which may amount 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).[4]
  • Patients in the Rehabilitation Wing were locked in their bedroom if they chose to remain there during the day or evening, but this was not recorded as seclusion.
  • Instances where patients were not freely able to exit their bedrooms following an episode of restraint were not recorded as seclusion events.
  • Night safety procedures (NSPs)[5] were not recorded as seclusion events, and were used across the entire Unit.
  • Night safety plans[6] were not always current or fully completed. Furthermore, night safety plans did not clearly specify the reason or rationale for the use of NSPs.
  • Consent, or the rationale for not obtaining consent, for the use of NSPs was not always documented in patients’ night safety plans.
  • Staff and patients spoken with did not have a clear understanding of patients’ entitlement to exit their rooms while NSPs were used.
  • Paperwork for reportable events was not always fully completed.
  • Medical assessment or advice was not routinely obtained, or not obtained in a timely manner after reportable events where there was potential harm to the patient.
  • Twenty-one percent of relevant staff had not completed or were out-of-date with their Safe Practice Effective Communication (SPEC) training.[7]
  • Complaints were not responded to within the required timeframes, and responses were often not personalised.
  • Patients did not have access to District Health Board (DHB) feedback and complaints forms without needing to ask staff.
  • Four patients in Tanerore did not have access to bathrooms overnight independently of staff, due to the use of NSPs.
  • The Rehabilitation Wing was not fit for purpose.
  • Patients in Tanerore were unable to access drinking water independently of staff.
  • Patients across the Unit were unable to access hot drinks independently of staff.
  • The courtyards in Tanerore did not provide adequate shade or shelter.


I recommend that:

  1. The seclusion room is never used as a bedroom. This is an amended repeat recommendation.
  2. The use of NSPs be recorded and reported as seclusion events. This is an amended repeat recommendation.
  3. If a patient is placed in a room or area, for any duration and at any time, from which they cannot freely exit, it is recorded as seclusion.
  4. Consent for NSPs is obtained and documented each time they are used. If consent is not obtained the rationale for this is clearly documented and regularly reviewed.
  5. The use of NSPs is based on individual risk assessments and night safety plans are current and fully completed.
  6. Patients subject to night safety procedures are made aware of their entitlement to leave their rooms during the night upon request, and this is documented.
  7. Reportable event documentation is fully completed.
  8. Medical assessment or advice is obtained in a timely manner following any reportable event where there is potential harm to the patient.
  9. All relevant staff are up-to-date with their SPEC training.
  10. Responses to complaints are personalised, and provided within the DHB policy’s timeframe.
  11. Complaint forms are available to patients on the Unit without needing to ask staff.
  12. Patients are able to access the bathroom independently of staff, unless deemed unsafe based on an individual risk assessment. If a patient is not able to access to the bathroom independently, the reasons are recorded and regularly reviewed.
  13. Patients have access to shade and shelter while using the courtyards in Tanerore.
  14. Patients are able to access drinking water and hot drinks independently of staff, unless this is considered unsafe based on an individual risk assessment. If a patient is not able to access drinking water or hot drinks independently, the reasons are recorded and regularly reviewed.
  15. The Rehabilitation Wing be upgraded.
  16. Medical assessment or advice is obtained in a timely manner following medication errors where there is potential harm to the patient.

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.

Te Korowai Whāriki – Central Regional Forensic Adult Mental Health Service’s Operations Manager and the Acting Director of Area Mental Health Services (DAMHS) Forensic and Rehabilitation Service provided Inspectors with additional information about this and two other Te Korowai Whāriki units[8] inspected at the same time.

They told my Inspectors they faced challenges with COVID-19, recruitment, and service demand.[9] They were aware of a growing waitlist of acutely unwell people in prisons and the community, compounded by patients being directed to the Service by courts.[10] They said this resulted in:

  • patients being admitted to the Service with high needs, requiring more staff attention;
  • a shortfall of beds, leaving patients accommodated in spaces other than bedrooms, affecting their dignity and privacy;
  • increased risks to patients and staff, and
  • diminishing staff morale.


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

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 two other units in the DHB which were conducted at the same time,[11] 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 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 have, however, highlighted these concerns with the Ministry of Health.[12] I also intend to conduct follow up inspections of all the Units.




[1]    When the term ‘Inspectors’ is used, this refers to the inspection team comprising one Senior Inspector and an Assistant Inspector.

[2]     The Unit was divided into two wings: the Rehabilitation Wing, and the intensive psychiatric care wing.

[3]     ‘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’. New Zealand Standards. Health and Disability Services (Restraint Minimisation and Safe Practice) Standards. Ministry of Health. 2008.

[4]     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.’

[5]     The Ministry of Health defines night safety procedures 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. 2018. Night Safety Procedures: Transitional Guideline.

[6]     A night safety plan is the individualised documentation required to be completed for a patient to be subject to a night safety procedure.

[7]     SPEC training was designed to support staff working within inpatient mental health units to reduce the incidence of restraints. SPEC training has a strong emphasis on prevention and therapeutic communication skills and strategies, alongside the provision of training in safe, and pain free personal restraint techniques. Accessed online 29 September 2020.

[8]     My findings on these two units are addressed in my Report on an unannounced inspection of Tāwhirimātea Forensic Rehabilitation Unit, Rātonga-Rua-O-Porirua Campus, under the Crimes of Torture Act 1989, (2021) Wellington, and Report on an unannounced inspection of Rangipapa Unit, Rātonga-Rua-O-Porirua Campus, under the Crimes of Torture Act 1989, (2021) Wellington.

[9]     Data provided by the DAMHS shows occupancy across the Service has averaged over 103 percent in the six months from January to June 2020.

[10]   When a court orders a person be referred to the Service, that person must be accommodated regardless of capacity and waiting lists.

[11]   The units inspected at the same time were Rangipapa and Tāwhirimātea.

[12]   For example, I have provided the Ministry of Health with my Report on an unannounced inspection of Haumietiketike Unit, Rātonga-Rua-O-Porirua Campus, under the Crimes of Torture Act 1989 (2021) and Final opinion of the Chief Ombudsman –  Oversight: An investigation into the Ministry of Health’s stewardship of hospital-level secure services for people with an intellectual disability (2021).

Last updated: