Report on an unannounced inspection of Wāhi Oranga Mental Health Admission Unit, Nelson Hospital, under the Crimes of Torture Act 1989
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 tāngata whai ora detained in secure units within New Zealand hospitals.
Between 29 March and 1 April 2021, Inspectors — whom I have authorised to carry out visits to places of detention under COTA on my behalf — made an unannounced inspection of Wāhi Oranga Mental Health Admission Unit (the Unit), which is located in the grounds of Nelson Hospital, Braemer Campus, Nelson.
Tāngata whai ora receive acute inpatient mental health services provided by Nelson Marlborough District Health Board’s (DHB’s) Adult Mental Health Services (the Service).
Summary of findings
My findings are:
- There was no evidence that any tangata whai ora had been subject to torture or other cruel, inhuman or degrading treatment or punishment.
- All the necessary paperwork to detain and treat tāngata whai ora on the Unit was on file.
- Tāngata whai ora said they felt safe on the Unit and that staff treated them with dignity and respect.
- The use of seclusion had reduced since my last visit in 2016.
- New admissions were not routinely placed in seclusion on admission, an improvement since my previous visit.
- Multi-Disciplinary Team meetings were professional, constructive and well attended, including by community mental health services.
- The Unit was spacious, clean, tidy, and well maintained.
- Voluntary tāngata whai ora were not accommodated in the Intensive Psychiatric Care unit (the IPC), an improvement since my previous visit.
- There was an activities programme (the ‘Wellbeing Programme’) on the Unit, which had been developed in consultation with tāngata whai ora.
- Cultural and spiritual support was available to tāngata whai ora.
- Tāngata whai ora had access to visitors and external communications.
- Tāngata whai ora had access to primary health care services.
- Staff said they generally felt safe on the Unit, and were complimentary and appreciative of the leadership and management of the Unit.
The issues that needed addressing are:
- The inappropriate long-term placement of tāngata whai ora on the Unit.
- Tāngata whai ora in seclusion did not have access to daily fresh air.
- Seclusion rooms were stark and gloomy.
- During the inspection a tangata whai ora was placed alone in the IPC, which met the definition of seclusion in the ‘Health and Disability Services (Restraint Minimisation and Safe Practice) Standards’ (2008). The IPC is not a designated seclusion area and the placement was not recorded as seclusion.
- There was a lack of information detailing the process for voluntary tāngata whai ora to enter and exit the Unit.
- Leave restrictions were in place for some voluntary tāngata whai ora.
- An instance of environmental restraint was not recorded.
- Some staff were not up-to-date with, or had not completed, Safe Practice Effective Communication (SPEC) training.
- Restraint records indicated that non-SPEC trained staff were involved in restraint events.
- Some complaints were not managed in accordance with the DHB’s Complaints Management Process.
- Tāngata whai ora, and their whānau, were not invited to attend their Multi-Disciplinary Team (MDT) meetings.
- The private information of tāngata whai ora could be viewed on a whiteboard through the nurse’s station window.
- There were no privacy curtains or blinds in the observation windows of the IPC bedrooms.
- There were limited activities available to tāngata whai ora during evenings and weekends.
- There was a large number of medication errors on the Unit.
I recommend that:
Follow-up inspections will be made at future dates to monitor implementation of my recommendations.
On completion of the inspection, my Inspectors met with representatives of the Unit’s leadership team to outline their initial observations.
The Nelson Marlborough District Health Board (the DHB) and the Ministry of Health received a copy of my provisional report and were invited to comment. The DHB and the Ministry of Health responded, and I have given regard to that feedback when preparing my final report. I am grateful to the DHB and the Ministry for their input, which has contributed positively to my final report.
 ‘Tāngata whai ora’ are users of mental health and addiction services. This term is often used interchangeably with ‘consumer’ or ‘service user’.
 When the term Inspectors is used in this report it refers to the inspection team comprising a Senior Inspector, Assistant Inspector, and two Specialist Advisors.
 Office of the Ombudsman report on an unannounced visit to Wahi Oranga Mental Health Inpatient Unit Under the Crimes of Torture Act 1989, April 2016.
 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’. Health and Disability Services (Restraint Minimisation and Safe Practice) Standards. Ministry of Health. 2008.
 SPEC training was designed to support staff working within inpatient mental health wards to reduce the incidence of restraints. SPEC training has a strong emphasis on prevention and therapeutic communication skills and strategies, alongside the provision of training in safe, and pain free personal restraint techniques.