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Report on an unannounced inspection of Te Whare Ahuru Mental Health Inpatient Unit, Hutt Hospital, under the Crimes of Torture Act 1989

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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 detained in secure units within New Zealand hospitals.

Between 10 and 12 March 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 Te Whare Ahuru Acute Inpatient Unit (the Unit), which is located in the grounds of the Hutt Hospital campus, Lower Hutt.  

Summary of findings

My findings are:

  • Files contained all the necessary paperwork to detain and treat clients on the Unit.
  • The use of seclusion had reduced since my last inspection (June 2016).
  • The use of restraint had reduced since my last inspection (June 2016).
  • Clinical notes were generally comprehensive.
  • Clients’ views on the Unit were generally positive.
  • Multi-disciplinary Team meetings were well attended by Unit staff and clinical discussions were thorough.
  • Clients were positive about the smoking cessation support provisions available.
  • Access to visitors was good, including in the more restrictive areas of the Unit.
  • Clients had good access to primary health care services.
  • The Transition Liaison Nurse role was a positive initiative.

The issues that needed addressing are:

  • Seclusion rooms, and other non-designated bedrooms, were being used as bedrooms when the Unit was over occupancy. This, in my opinion, has the potential to 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’);[2]
  • Clients in de-escalation had no privacy when using the telephone;
  • The Te Rangi Marie area as a whole was not fit for purpose;
  • Client access to the toilet in the Te Rangi Marie area could potentially be problematic;
  • Inspectors learnt of an incident where a client, unable to access any toilet, subsequently passed a bowel motion in the corridor area of Te Rangi Marie. I consider this to be of concern and the resulting outcome for the client was unacceptable;
  • There was a lack of information detailing the process for voluntary clients to enter and exit the Unit;
  • Leave restrictions were in place for voluntary clients and at the time of inspection they were not free to leave at will;
  • Over a third of staff were out of date with the Safe Practice Effective Communication (SPEC) training;
  • Sensory modulation facilities were not well advertised on the Unit or accessible to clients;
  • Welcome/information packs were not routinely provided to clients on admission;
  • There was no information about the complaints process on display throughout the Unit. The role of the District Inspectors was not well advertised;
  • Consent to treatment forms were not routinely completed;
  • Clients were not invited to their Multi-Disciplinary Team (MDT) meetings and did not regularly receive feedback on the outcomes of these meetings;
  • The building was not fit for purpose;
  • The standard of cleanliness and facilities maintenance was inadequate;
  • Clients’ private health information was compromised as a result of poor Unit design and staff not always being mindful of the issue;
  • Cultural support was lacking for Māori clients;
  • Clients on the acute ward were not always able to use a telephone in private; and
  • The Unit had employed external security staff to increase staffing numbers, despite these staff not having mental health specific training or an adequate job description.

[1]     When the term Inspectors is used, this refers to the inspection team comprising a Senior Inspector, an Inspector, Assistant Inspector and two specialist advisors.

[2]     UN Convention against Torture, Article 16(1): “Each State Party shall undertake to prevent 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 1, when such acts are committed by or at the insitgation of or with the consent or acquiesence 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.”

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