Open main menu Close main menu

Report on an unannounced inspection of Tiaho Mai Mental Health Inpatient Unit, Middlemore Hospital, 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 service users[1] detained in secure units within New Zealand hospitals.

Between 23 and 25 June 2020, four Inspectors[2] — whom I have authorised to carry out visits to places of detention under COTA on my behalf — made an unannounced inspection of Tiaho Mai[3] Mental Health Inpatient Unit (the Unit), which is located in the grounds of Middlemore Hospital Campus, Otahuhu, Auckland.

Service users receive acute mental health services provided by Counties Manukau District Health Board’s (DHB’s) Adult Mental Health Services (The Service).

Summary of findings

My findings are:

  • There was no evidence that service users had been subject to torture or other cruel, inhuman or degrading treatment or punishment.
  • Seclusion facilities were modern and clean, with natural light and access to fresh air.
  • The care of service users in seclusion was good, with cultural support from the Kai Manaaki, and the retreat area was well utilised.
  • Service users’ views of the Unit were positive and service users felt staff treated them with dignity and respect.
  • The Unit did not go over occupancy, an achievement from my previous inspection in 2015.[4]
  • Up-to-date contact details for District Inspectors (DIs) were visible in each of the wards and the DIs had an active presence on the Unit.
  • Files contained all the necessary paperwork to detain and treat service users on the Unit, except for one voluntary[5] service user who did not have consent documentation on file.
  • Information on the Mental Health (Compulsory Assessment and Treatment) Act 1992 (MHA) process and the Unit’s privacy policy was clearly displayed throughout the Unit, in an accessible format.
  • The recently built Unit was light, modern, therapeutic, and considered in its design. All bedrooms had en-suite bathrooms and internal courtyards were accessible to service users throughout the day.
  • The thoughtful design of Nga Whetu Marama[6] and the admission suite was commendable. Service users were welcomed to the Unit in an environment that was open and friendly.
  • The Unit was clean, tidy and well maintained throughout.
  • Service users had independent access to hot and cold drinks throughout the Unit.
  • Therapeutic programmes were being rolled out and feedback from service users on these was positive.
  • Service users had good access to telephones and were able to keep their personal cell phones on the Unit. Any decision to remove cell phones was based on an individual risk assessment.
  • Cultural and spiritual support was evident on the Unit and te ao Maaori perspectives were integrated in the facility’s design, care of service users in seclusion, and the established roles of the Kai Manaaki, Kaumatua and Kuia on the Unit.
  • Service users’ physical health care needs appeared to be well met.
  • Staff were regularly observed on the Unit and engaged with service users.

The issues that needed addressing are:

  • The collation and reporting of seclusion data was incomplete.
  • The collation and reporting of restraint data was incomplete.
  • Data on the number of staff who were up-to-date with mandatory training at the time of the inspection was not available.
  • Consent paperwork for a voluntary service user was incomplete.
  • There was a lack of information detailing the process for voluntary service users to enter and exit the Unit.
  • Leave restrictions were in place for voluntary service users and at the time of inspection they were not free to leave at will.
  • Sensory modulation facilities were not well advertised on the Unit or accessible to service users.
  • There was no information about the complaints process on display throughout the Unit and the process was not clearly understood by service users.
  • Consent to treatment forms were not always on file.
  • Completion of admission forms and orientation checklists was variable.
  • Service users were not invited to their Multi-Disciplinary Team (MDT) meetings and did not regularly receive feedback on the outcomes of these meetings.
  • While there were activities available on the Unit, they were not individualised or tailored to the service user group.
  • Data on staffing levels, sickness, and turnover was not available.
  • Staffing levels and staff safety continued to be an issue on the Unit.

[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 a Senior Inspector, Inspector and two Assistant Inspectors.

[3]     Tiaho Mai translates as ‘the light that comes from the moon and the stars – shine here’. See 

[4]     Office of the Ombudsman report on an unannounced inspection to Tiaho Mai Mental Health Inpatient Unit under the Crimes of Torture Act 1989, October 2015.

[5]     A voluntary service user (sometimes called an 'informal patient') is someone who has been admitted as an inpatient to a psychiatric ward but is not detained under the MHA. This means that the service user has agreed to have treatment and has the right to suspend or stop that treatment. The service user has the right to leave the facility at any time.

[6]     Nga Whetu Marama is the marae/ whare situated alongside the Unit. Nga Whetu Marama translates to ‘the bright stars’ and was named by the local Kaumatua and Kuia of Tainui.

Last updated: