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Report on an unannounced inspection of Stanford House, Whanganui Hospital, under the Crimes of Torture Act 1989

Issue date:

Executive summary


Ombudsmen are 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 clients[1] detained in secure units within New Zealand hospitals.

Between 14 and 17 September 2020, four Inspectors[2] — whom I have authorised to carry out visits to places of detention under COTA on my behalf — made an announced four-day inspection of Stanford House, located in the grounds of Whanganui Hospital.

Summary of findings

My findings are:

  • There was no evidence that any patient had been subject to torture or cruel, inhuman or degrading treatment or punishment.
  • There were no instances of seclusion or restraint between 1 March 2020 and 31 August 2020.
  • The sensory modulation room was well signposted, and clients could easily access the room to relax and enjoy time away from the Unit.
  • Inspectors saw empathetic, polite and meaningful interactions between staff and clients.
  • Whānau felt welcomed and respected by Unit staff.
  • The Unit had adopted a co-design approach to care, and encouraged clients and whānau to be involved in decision-making.
  • Special Patient Review (SPR) and Multi-Disciplinary Team (MDT) meetings were thorough and client-centric. Clients and whānau were invited to both SPR and MDT meetings.
  • The Unit was clean, spacious and homely. Unit management were proactive in maintaining the Unit and its facilities.
  • A range of meaningful activities were available to clients, both on and off the Unit.
  • The Unit provided strong cultural support to clients.
  • Staff encouraged visits for clients.


I have no recommendations to make.

Follow up inspections will be made to monitor the treatment of clients.

Good practice

I saw examples of good practice, including that:

  • Clients played an active role in SPR and MDT Meetings, supported by staff, volunteers, and whānau.
  • Unit staff had developed user-friendly Rongoā Pānui Medication Cards to help clients and whānau understand prescribed medication and its side effects.
  • Staff were proactively working to improve their understanding of te ao Māori and tikanga Māori.


On completion of the inspection, my Inspectors met with Unit staff to outline their initial observations.

A provisional draft of this report was provided to the Manager and Director of Area Mental Health Services for feedback prior to publication.




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

[2]     When the term ‘Inspectors’ is used, this refers to the inspection team comprising two Inspectors and two Specialist Advisors.

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