Open main menu Close main menu

Report on an unannounced inspection of Rangipapa 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 clients[1] detained in secure units within New Zealand hospitals.

Between 14 and 16 July 2020, two Inspectors[2] — whom I have authorised to carry out visits to places of detention under COTA on my behalf — made an unannounced inspection of Rangipapa 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 clients had been subject to torture or other cruel or inhuman treatment or punishment.
  • Clients spoken with felt safe and that they were treated with dignity and respect.
  • There were no instances of seclusion or restraint in the six months prior to the inspection.
  • Files contained the necessary paperwork to detain and treat clients on the Unit, with the exception of one client.
  • Consent to treatment forms were on file for all clients.
  • The complaints process appeared to be well understood by staff and clients. Clients had a good understanding of the District Inspectors’ role.
  • Access to leave was encouraged and well utilised.
  • Clients were invited to attend their Huihui multi-disciplinary team meetings and provided with feedback of the outcomes of these meetings.
  • Worn and damaged carpets had been replaced.
  • There were no concerns about the quality or quantity of the meal service.
  • There was a wide range of activities available to clients, including group and 1:1 settings.
  • Cultural and spiritual support was evident and well received by clients.
  • Access to visits and communication was good, including during COVID-19 Alert Levels 4, 3 and 2.[3] Clients had individualised phone plans and could make calls in private.
  • Clients had access to primary health care services.
  • Staff were identifiable on the Unit.

The issues that needed addressing are:

  • Seclusion rooms were being used as bedrooms. This 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]
  • Female clients were spending prolonged periods of time in seclusion rooms, due to lack of available bedrooms on the Unit.
  • Female clients were being admitted directly into seclusion rooms.
  • Female clients were treated inequitably, particularly by admission into, and long term stays in seclusion rooms.
  • One of the seclusion room windows had graffiti of a sexually violent nature.
  • The outside area in Rangimārie did not have any seating or shade.
  • Night Safety Orders (NSOs)[5] were not being recorded as seclusion events and NSO paperwork did not clearly specify the reasoning or rationale for their use.
  • Record keeping surrounding the use of NSOs was inconsistent and incomplete. It was difficult to assess when an NSO had been implemented and subsequently terminated. There was also evidence of NSOs being used outside of the period for which they were in force.
  • Clients could not access complaint forms independent of staff.
  • Client files were generally disorganised and forms were inconsistently completed.
  • The Unit had a number of ongoing maintenance issues, including faulty air conditioning and leaks.
  • Clients did not have independent access to secure courtyards.
  • The courtyard in Aniwaniwa was small, had minimal seating, and did not provide adequate shade.
  • Clients were unable to access hot drinks independent of staff.
  • The Unit had a high and increasing rate of staff turnover.


I recommend that:

  1. Seclusion rooms, and other non-designated bedrooms, are never used as bedrooms.
  2. Clients are not kept in seclusion rooms for prolonged periods of time, unless clinically necessary.
  3. Female clients are not admitted into seclusion rooms, unless clinically necessary.
  4. The use of seclusion rooms without clinical rationale be reviewed, with a particular focus on the equitable treatment of female clients.
  5. The seclusion room window covered in graffiti be replaced. This is an amended repeat recommendation.[6]
  6. Seating and shade is provided in the Rangimārie exercise yard. This is an amended repeat recommendation.
  7. The use of Night Safety Orders be recorded and reported as seclusion events. This is a repeat recommendation.
  8. The Service take all necessary steps to ensure comprehensive and accurate collection and reporting on the use of Night Safety Orders.
  9. Complaint forms are available to clients, independent of staff.
  10. Complete and correct documentation is kept in respect of all client records.
  11. Ongoing maintenance issues are addressed (with particular attention to the variation in temperatures across the Unit).
  12. All clients have unrestricted access to courtyards during the day, unless deemed inappropriate for individual clients on a clinical or safety basis.
  13. Shade is provided in the Aniwaniwa exercise yard. This is an amended repeat recommendation.
  14. Clients are able to freely access hot drinks, unless deemed unsafe based on individual risk assessment.
  15. The Unit take urgent action to address the high staff turnover.


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.

The Service’s Operations Manager and the Acting Director of Area Mental Health Services Forensic and Rehabilitation Service provided Inspectors with additional information about this and two other Te Korowai Whāriki Units[7] inspected at the same time.

They told my Inspectors they faced challenges with COVID-19, recruitment, and service demand.[8] 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.[9] They said this resulted in:

  • patients being admitted to the Service with high needs, requiring more staff attention than those admitted in a timely manner;
  • 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.

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[10], 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.

While I acknowledge the comments, 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 my concerns with the Ministry of Health.[11] I also intend to conduct follow up inspections of all the Units.




[1]     A person who uses mental health and addiction services. This term is often used interchangeably with consumer, patient, or tāngata whai ora.

[2]     When the term Inspectors is used, this refers to the inspection team comprising of two Inspectors.

[3]     See for more about New Zealand’s COVID-19 alert system.

[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]     Recommendations from my 2016 report are on page 11.

[7]     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 Pūrehurehu Unit, Rātonga-Rua-O-Porirua Campus, under the Crimes of Torture Act 1989, (2021) Wellington.

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

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

[10]   The units inspected at the same time were Tāwhirimātea and Pūrehurehu.

[11]   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: