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Report on an unannounced inspection of Ward 10a and Helensburgh Cottage, Wakari Hospital Dunedin, 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 of detention and treatment of patients[1] detained in secure units within New Zealand hospitals.

Patients receive treatment and rehabilitation services provided by Southern District Health Board’s (DHB’s) Mental Health Addictions and Intellectual Disability Service (the Service).

The Service are contracted by the Ministry of Health’s Regional Intellectual Disability Secure Services (RIDSS).[2]

Between 3 and 7 May 2021, two Inspectors[3] — whom I have authorised to carry out visits to places of detention under COTA on my behalf — made an unannounced inspection of Ward 10a (the Ward) and the Helensburgh Cottage (the Cottage), which are located in the grounds of Wakari Hospital, Dunedin.

A note about terminology

I acknowledge the importance of language around disability, and that people have differing views on the meaning, accuracy, and effects of particular terms. I have chosen to use the term ‘intellectual disability’ in this report where patients are detained under the Intellectual Disability (Compulsory Care and Rehabilitation) Act 2003 (the IDCCR Act).

There is no single definition of ‘intellectual disability’. People with intellectual disabilities are a diverse group who may experience challenges understanding new or complex information, learning new skills, and living independently. The IDCCR Act provides a legal definition[4] and, relevant to this report, a framework for the compulsory care, rehabilitation, and special rights of people with intellectual disabilities.  

Other terms used to refer to people with intellectual disabilities include ‘tangata whaikaha hinengaro’, ‘intellectually impaired people’, or ‘people with a learning disability’.

Summary of findings

My findings are:

  • Most patients spoken with felt safe and confirmed that they were treated with dignity and respect. Whānau spoken with were also positive regarding the treatment of their family members.
  • The Ward and Cottage did not use Night Safety Orders.
  • Patients could wear their own clothing when in seclusion; the Ward did not use anti-ligature gowns in seclusion.
  • Staff were up-to-date with mandatory training. It was pleasing to see that this matter had been rectified since my predecessor’s previous inspection in 2014.[5]
  • Files contained the necessary paperwork to detain and treat the patients on the Ward and Cottage.
  • The ‘Ward Rounds’ was a positive initiative.
  • Care and Rehabilitation Plans / Treatment Plans were individualised and detailed.
  • Patients were able to keep most of their toiletries and could lock their bedroom doors and bathrooms.
  • Patients had access to snacks and Inspectors were pleased to see patients could leave the dining area once they finished their meals.
  • All patients had access to the courtyard, fresh air and outdoor exercise.
  • The Service had adopted the Safewards approach,[6] which was well embedded on the Ward. The Mutual Help Meeting[7], in particular, was a positive initiative.
  • Patients’ access to leave was well utilised and supported by Ward and Cottage staff.
  • There were no issues with visits and there was active whānau involvement.
  • There were no prescriptive times to access phones.
  • Patients had good access to primary health care services.
  • Interactions between staff and patients were respectful and staff appeared to know their patients well. Leadership on the Ward and Cottage was visible.
  • Inspectors observed a dedicated team in both the Ward and Cottage.
  • Staff reported feeling supported by the leadership team.
  • Clinical supervision was actively promoted and staff were supported to attend.

The issues that needed addressing are:

  • The mixing of differing patient status on the Ward and Cottage (forensic and non-forensic).
  • Non-forensic patients were subject to restrictive practices due to the Ward being a forensic medium secure environment.
  • There was a lack of gender separation on the Ward.
  • The District Health Boards’ (DHB) Restraint Minimisation and Seclusion Guidelines - MHAID Service (District) definition of seclusion did not align with the Ministry of Health’s (MOH) definition of seclusion.
  • Seclusion events were being incorrectly recorded as environmental restraint.
  • Staff had used a surgical mask on a patient during a restraint event.
  • Use of non-approved restraint – use of surgical mask.
  • The Sensory Modulation room was not operational at the time of inspection.
  • Information on the complaints process was not displayed on the Ward or Cottage.
  • Contact details for the District Inspector were not visible or clearly displayed on the Ward or Cottage.
  • Copies of the Health and Disability Commissioner’s Consumer Rights were not well displayed throughout the Ward and Cottage, nor was it available in Easy Read or accessible format.
  • There was no independent Consumer Advocate available to patients accommodated in either the Ward or Cottage.
  • The Ward was not fit-for-purpose and was in critical need of upgrade and redevelopment, an issue my predecessor raised in their 2014 report. I consider the current state of the Ward to be unacceptable and compromised patient and staff safety as well as patient’s dignity.
  • The Ward required significant maintenance. Carpets, beds and soft furnishings needed urgent replacement.
  • Patients could not access hot and cold drinks independent of staff on the Ward.
  • The activities programme was not available in the evenings or at weekends. 
  • Cultural support was limited.
  • Access to the telephone was not available independent of staff and did not afford privacy, an issue my predecessor raised in their 2014 report.


I recommend that:

  1. Forensic patients are accommodated separately from non-forensic patients.
  2. ‘Medium secure restrictive practices’ are not placed on non-forensic patients.
  3. Gender separation is provided on the Ward wherever possible.
  4. The DHBs Restraint Minimisation and Seclusion Guidelines - MHAID Service (District) use the MOH’s definition of seclusion.
  5. All events which meet the definition of seclusion as set out by the Ministry of Health, are recorded as seclusion events.
  6. Facial coverings or masks are never applied to a patient when they are being restrained.
  7. Staff only use DHB approved restraint techniques.
  8. The Sensory Modulation Room is made operational.
  9. Independent Consumer Advocate support is available to patients.
  10. The Ward is rebuilt or at the very least upgraded, including remedying ligature points, upgrading soft furnishings, carpets and bedding. This is an amended repeat recommendation.
  11. Cleanliness and facilities maintenance issues are attended to as a matter of priority.
  12. Patients can access drinking water and hot drinks independently of staff, unless this is considered unsafe based on an individual risk assessment. If a patient is not able to access drinking water or hot drinks independently, the reasons are recorded and regularly reviewed.
  13. The activities programme is extended to evenings and weekends.
  14. Regular and ongoing access to Kaioranga Hauora Māori[8] support is provided.
  15. Patients in the Ward and Cottage can make a telephone call in private and independent of staff. This is an amended repeat recommendation.


I intend to monitor the implementation of my recommendations, including conducting follow-up inspections at future dates.

Feedback meeting

On completion of the inspection, my Inspectors met with the Charge Nurse Manager and the General Manager, to outline their initial observations. A written copy of the initial observations was provided to the facility on 7 May 2021.


My provisional report was forwarded to the Service for comment. A copy of my provisional report was also sent to the Ministry of Health for comment.

The District Health Board (DHB) responded to my provisional report.  Their comments are set out within the report.  In response to my provisional report, the Ministry of Health stated they supported my recommendations 8, 10, 11, 15 and 16. The Ministry of Health also advised they would follow up with the DHB and the District Inspectors regarding recommendations 7, 9, 12, 13, 14 and 17. The Ministry of Health stated that they were ‘engaging in a capacity planning process that has identified the need for both remedial work and additional bed planning nationwide. It is likely this will progress to an investment proposal process to support government consideration of future needs’.


[1]     The Ward referred to people under the IDCCR Act, the Mental Health (Compulsory Assessment Treatment) Act 1992 and people under Criminal Procedure (Mentally Impaired Persons) Act 2003 (CPMIP Act) as ‘patients’.

[2]     RIDSS provide hospital level secure residential services and assessment beds. Both Auckland and Wellington RIDSS services provide some beds for clients transferring from other regions. RIDSS are contracted through the DHBs.

[3]     When the term Inspectors is used, this refers to the inspection team comprising of two Inspectors.

[4]     Section 7.

[5]     Office of the Ombudsman report on an unannounced inspection to Ward 10a Wakari Hospital under the Crimes of Torture Act 1989, September 2014.

[6]     Safewards is a model of care, developed in the United Kingdom, designed to reduce conflict (aggression, rule breaking) and containment (coerced medications, restraint and seclusion) in acute adult mental health inpatient units. For a more comprehensive description of the Safewards model, go to the Safewards website at:

[7]     Patient-led community meetings were held three times a week in the Ward and Cottage.

[8]     Māori cultural worker.

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