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Report on an unannounced inspection of Te Whetu Tāwera Adult Acute Mental Health Unit, Auckland City 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 service users[1] detained in secure units within New Zealand hospitals.

Between 19 and 22 November 2019, Inspectors[2] — whom I have authorised to carry out visits to places of detention under COTA on my behalf — made an unannounced inspection of Te Whetu Tāwera Adult Acute Mental Health Unit (the Unit), which is located in the grounds of Auckland City Hospital, Auckland.

Summary of findings

My findings are:

  • There was no evidence that any service user had been subject to torture or other cruel, inhuman or degrading treatment or punishment.
  • The Unit was making a concerted effort to reduce seclusion.
  • Seclusion and restraint paperwork was detailed and robust.
  • All files reviewed contained all the necessary paperwork to detain and treat service users on the Unit.
  • Consent to treatment forms for service users were on all files reviewed.
  • Progress and handover notes were thorough and kept up-to-date.
  • The Unit had separate accommodation areas for women, along with a separate accommodation wing located on Te Whitinga ward, for vulnerable women.
  • The physiotherapist was having a positive impact, with service users reducing their use of pain medication for muscular-skeletal issues.
  • Volunteers were a positive addition to the Unit.
  • There was a comprehensive programme of activities for service users to participate in.
  • The recreational officer on Te Tūmanako ward was a welcome addition to the team.

The issues that needed addressing are:

  • The Auckland District Health Board’s (ADHB) Search for Illicit Substances and Hazardous Items - Te Whetu Tawera policy and practice raised concerns.
  • Robust systems were not in place to record and monitor drug testing of service users.
  • Service users in seclusion were provided with a cardboard receptacle in which to urinate or defecate. Inspectors noted the receptacle was visible from the seclusion door window and the observation room, which posed a serious risk to service users’ privacy and dignity.
  • Service users in seclusion and the High Dependency Unit/Arohaina did not have access to fresh air.
  • Service users and staff felt unsafe on Te Tūmanako ward.
  • The Unit did not have a formal complaint form. The complaints process was not well advertised on the wards. Service users did not know how to make a complaint.
  • Consumer Advisors were inaccessible to service users when the corridor doors to the activities area were locked. Service users on Te Tūmanako were limited in their ability to access the Consumer Advisors due to their location in the activities area, coupled with Consumer Advisors not visiting the wards.
  • The Unit did not produce care/treatment plans and therefore service users were not given documentation which outlined their planned progression.
  • Service users did not attend Multi-disciplinary Meetings (MDT), and staff were unclear as to who was responsible for providing information to the service user from MDT meetings.
  • Service users could not lock their bedroom doors.
  • Service users on Te Tūmanako had no ability to access hot water independently of staff.
  • Service users had restricted access to the activities area when the corridor doors were locked.
  • Activities/programmes available to service users in the evening/weekend were limited.
  • Service users on Te Tūmanako had restricted access to telephones.
  • Service users were required to go to the Emergency Department for medical assessment and treatment.

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

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

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