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Report on an unannounced inspection of Tāwhirimātea Rehabilitation 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 Tāwhirimātea  Rehabilitation Unit (the Unit), which is located in the grounds of Rātonga-Rua-O-Porirua 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.
  • My Inspectors saw staff providing empathetic, tailored and responsive care to clients in de-escalation.
  • There was a significant decrease in the use of seclusion since my 2016 Report.
  • There was a significant decrease in the use of restraint since my 2016 Report.
  • Clients reported feeling safe on the Unit and that staff treated them with respect.
  • Information about the District Inspector, the Health and Disability Commissioner's Code of Health and Disability Services Consumers' Rights and the Unit’s complaints process was displayed across the Unit.
  • Clients were invited to attend their Huihui Multi-Disciplinary Team Meetings (Huihui) and were provided with feedback of the outcomes of these meetings.
  • Inspectors attended Huihui and observed them to be comprehensive and client-centred.
  • There was a range of activities available to clients, both on and off the Unit.
  • 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] Male 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:

  • Clients were sleeping in hallways, in a sensory modulation room, and in an office space without natural light, privacy or sufficient ventilation. In my opinion 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]
  • Multiple staff were not up-to-date with Safe Practice Effective Communication (SPEC) training at the time of inspection.
  • Sensory modulation rooms were not operational during the inspection.
  • The Unit’s process for stand-down periods was not clear to clients.
  • Complaint forms were not available to clients without staff assistance.
  • Not all files contained consent to treatment forms.
  • Female clients without leave could not freely access the courtyard without staff supervision, due to a lack of fencing around the female outdoor area.
  • Two clients’ bedrooms did not have privacy blinds.
  • Some of the Unit’s furnishings were damaged, dirty and in need of repair or replacement.
  • There was a blanket restriction on access to the kitchen, which adversely affected clients’ ability to access hot water for drinks.
  • Female clients could not access the telephone independently of staff.


I recommend that:

  1. Clients are never accommodated in hallways, sensory modulation rooms, or rooms without natural light or sufficient ventilation. This is an amended repeat recommendation.[5]
  2. All relevant staff are up-to-date with their SPEC training.
  3. Both sensory modulation rooms are operational, advertised and available to clients throughout the day.
  4. The Unit clarifies its policy and procedures for stand-down periods, and shares this information with clients.
  5. Complaint forms are available to clients, independent of staff.
  6. Clients’ consent to treatment forms are completed on admission and any other time consent is sought, and any refusal of consent is recorded in their files. This is an amended repeat recommendation.
  7. The Unit erect fencing around the female outdoor area to enable clients to freely access the courtyard without staff supervision.
  8. Clients’ bedrooms have internal privacy blinds installed in the observation panel.
  9. Clients’ bedrooms have appropriate storage facilities where clients can store their belongings.
  10. Clients can freely access hot drinks, unless deemed unsafe based on individual risk assessment.
  11. All clients have access to a telephone, independent of staff, unless deemed unsafe based on individual risk assessment.


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[1] inspected at the same time.

They told my Inspectors they faced challenges with COVID-19, recruitment, and service demand.[2] 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.[3] 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.


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[4], 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.[5] I also intend to conduct follow up inspections of all the Units.


[1]     Addressed in my Report on an unannounced inspection of Rangipapa 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.

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

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

[4]     The units inspected at the same time were Rangipapa and Pūrehurehu.

[5]     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).


[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]     Recommendations from my 2016 report are on page 14.

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