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Report on an unannounced inspection of STAR 1 (Services for Treatment, Assessment & Rehabilitation), Palmerston North 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 patients detained in secure units within New Zealand hospitals.

Between 29 September and 1 October 2020, Inspectors[1] — whom I have authorised to carry out visits to places of detention under COTA on my behalf — made an unannounced inspection of STAR 1[2], which is located in the grounds of Palmerston North Hospital in the MidCentral District Health Board region.

Summary of findings

My findings are:

  • staff engaged with the patients and their family in a warm and respectful way;
  • staff used caring and supportive language when speaking about the patients.

The issues that needed addressing are:

  • alternative interventions to de-escalate situations should always be tried before using personal restraint and pro re nata medication;
  • the Unit was not fit-for-purpose:
    • it had an institutional rather than homely feel;
    • there was a lack of space to conduct group activities;
    • there was no dining room and no kitchen for patients to use;
    • the outdoor space was unsafe and not therapeutic;
    • access to the outdoor space was restricted when the patient lounge was in use;
    • there were no quiet spaces for patients outside of their room;
    • the patient lounge was small and poorly resourced; and
    • patient movement was restricted by staff seated in the doorway of a patient’s room.


I recommend that:

  1. Least restrictive measures are attempted by staff (and recorded) to de-escalate situations before personal restraint and pro re nata medication is considered.
  2. There is a sensory modulation room with appropriate resources, light, ventilation and uncluttered space. This is an amended repeat recommendation. 
  3. Patients and their whānau are made aware of how to make a complaint, and brochures and a complaint box are readily available in the Unit. 
  4. The Facility has fit for purpose areas for: quiet time outside of bedrooms, interacting with other patients and visitors and engaging in cultural and religious groups and activities, physical exercise and relaxation outside, and dining and access to snacks and drinks. This is an amended repeat recommendation.
  5. Patients are provided with the opportunity to engage in group activities.

Follow up inspections will be made at future dates to monitor implementation of my recommendations.

Feedback meeting

On completion of the inspection, my Inspectors met with representatives of MidCentral District Health Board (MDHB) and the Unit’s leadership team, to summarise their initial observations.


[1]     When the term Inspectors is used, this refers to the inspection team comprising of the OPCAT Manager, Senior Inspectors and Inspectors.

[2]     Services for Treatment, Assessment and Rehabilitation.

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