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Report on an unannounced inspection of Te Awhina, 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 tāngata whai ora[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 Te Awhina (the Unit), which is 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.
  • The Unit had eliminated the use of Night Safety Orders (NSOs) shortly prior to the inspection.
  • Tāngata whai ora and whānau had positive things to say about the Unit.
  • Tāngata whai ora were invited to their multi-disciplinary team (MDT) meetings.
  • The Unit was generally clean, tidy and well maintained. However, refurbishment of the Unit was completed in late 2012 and the Unit was showing signs of wear and tear.
  • All rooms had adequate natural light, with the exception of the de-stimulation or quiet room in Kiwi.
  • Courtyards were generally unlocked during the day, with the exception of the courtyard located off the day services area.
  • Haumoana Navigators were actively providing cultural support to tāngata whai ora on the Unit during the inspection.
  • There were no concerns with tāngata whai ora access to visitors and external communications.
  • Staff were generally optimistic about the direction of the Unit and they felt supported by the new management team.

The issues that need addressing are:

  • The de-stimulation room in the Kiwi wing was used as a bedroom during the inspection, despite having no natural light.
  • The Unit used the seclusion[3] area in Stanford House[4], which was not fit for purpose and should not have been used to seclude tāngata whai ora from the Unit.
  • Seclusion in the six months prior to my inspection had increased significantly compared to the same period before my previous inspection in 2017.
  • Two-thirds of tāngata whai ora secluded by the Unit were Māori, totalling almost 90 percent of the Unit’s total seclusion hours in the six-month period. Māori made up approximately 46 percent of tāngata whai ora at the Unit over the same period.
  • Not all seclusion events were being recorded by the Unit.
  • There was evidence that a security guard had been present during a seclusion event and had directly interacted with the tangata whai ora, including verbally directing the tangata whai ora.
  • The furnishings in the Sensory Modulation room were tired and uncomfortable. The light was not fully operational and the light fittings had a large a number of dead bugs in them.
  • There was no information about the DHB complaints process or complaints forms on the Unit. Tāngata whai ora did not have a clear understanding of the complaints process.
  • Duly Authorised Officers (DAO)[5] did not routinely record their name on the detaining paperwork given to tāngata whai ora.
  • Tāngata whai ora could not open and close their blinds without staff assistance, meaning they could not independently control the level of natural light in their own bedrooms.
  • A greater degree of privacy was needed for tāngata whai ora residing in the Kererū wing.
  • Activities on the Unit were limited and staff told my Inspectors that they were not adequately resourced to implement the activities programme.
  • Tāngata whai ora were not receiving timely physical examinations on admission to the Unit.
  • The number of medication errors in the six months prior to the inspection was high and remedial action had not addressed the issue.


I recommend that:

  1. The de-stimulation room in Kiwi is not used as a bedroom.
  2. The Unit never seclude tāngata whai ora in Stanford House.
  3. The high and increasing use of seclusion is addressed with a particular focus on equitable treatment of Māori.
  4. The Unit ensures that all events which meet the definition of seclusion are recorded as seclusion events.
  5. Security guards are never involved in the care of tāngata whai ora.
  6. The furnishings and light fittings in the Sensory Modulation Room are replaced or upgraded.
  7. The complaints process, including complaint forms, are well advertised and accessible to tāngata whai ora on the Unit and their whānau (This is an amended repeat recommendation).
  8. Duly Authorised Officers complete detaining paperwork with their name.
  9. Tāngata whai ora are able to control the level of natural light in their bedrooms independently of staff.
  10. Rooms without external window coverings are not used as bedrooms.
  11. The privacy of tāngata whai ora residing in Kererū is improved.
  12. Additional resources and supervision are available for programmes and activities on the Unit.
  13. Tāngata whai ora receive timely physical examination on admission. If the examination is unable to occur, the reasons why, and a plan for the examination to occur, are documented in the clinical file.
  14. The DHB develop and implement a plan to significantly reduce the number of medication errors.

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 the Unit’s leadership team, 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 client.

[2]     When the term Inspectors is used, this refers to the inspection team comprising a Senior Inspector, Inspector, Specialist Advisor and Administrator.

[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’. Ministry of Health. Seclusion under the Mental Health (Compulsory Assessment and Treatment) Act 1992. Ministry of Health, Wellington, 2010.

[4]     Stanford House is an extended secure rehabilitation regional forensic service located on the grounds of Whanganui hospital. See Report on an unannounced inspection of Stanford House, Whanganui Hospital, under the Crimes of Torture Act 1989, July 2021, Wellington.

[5]     A Duly Authorised Officer (DAO) is authorised by the Director of Area Mental Health Services to perform the functions and exercise the powers conferred on the DAO under the Mental Health Act.  See:

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