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Report on an unannounced inspection of Ward 21, Palmerston North Hospital, under the Crimes of Torture Act 1989

Issue date:

Executive Summary


Ombudsmen are designated 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[1] detained in secure units within Aotearoa New Zealand hospitals.

Between 18 and 21 May 2021, 2 Inspectors [2] — whom I have authorised to carry out visits to places of detention under COTA on my behalf — made an unannounced four day inspection of Ward 21, Palmerston North Hospital.

Summary of findings

My findings are:

  • Tāngata whai ora were positive overall about their treatment and care on the Ward.
  • Tāngata whai ora and whānau were included in multi-disciplinary team meetings regarding their care and treatment.
  • There was no routine practice of locking tāngata whai ora in their bedrooms overnight.

The issues that need addressing are:

  • The Ward was consistently over-occupied, with tāngata whai ora numbers regularly over the funded 24 beds.[3]
  • Staff numbers were not always adequate to care for the number of tāngata whai ora on the Ward.
  • The Ward, especially the High Needs Unit, was in need of upgrades and urgent maintenance work.
  • Appropriate consent to treatment paperwork was not completed for voluntary tāngata whai ora.
  • Seclusion paperwork was missing some key information, such as justification for ongoing seclusion, and how seclusion was safely ended.
  • Māori were disproportionately subjected to seclusion.
  • Young people were subjected to restraint and seclusion.
  • Seventeen percent of relevant staff were not up-to-date with Safe Practice Effective Communication (SPEC) training, and a number were out-of-date with other mandatory training.
  • Admission medical assessments could take, on average, six days to be completed.
  • Voluntary tāngata whai ora were subject to leave restrictions.
  • There were a high number of medication errors.
  • There were issues with the complaints process, so that tāngata whai ora could not make a written complaint without staff assistance, and concerns about treatment were sometimes treated as feedback rather than complaints.
  • There were insufficient activities and programmes for tāngata whai ora, especially in the evenings and weekends.
  • Visits did not always take place in dedicated visiting areas, potentially compromising the privacy of others on the Ward.
  • Tāngata whai ora did not have independent access to telephones.


I recommend that:

  1. Seclusion records are sufficiently detailed, at a minimum, in line with the Seclusion Policy and Seclusion Procedure.
  2. All necessary steps are taken to reduce the disproportionate seclusion of Māori.
  3. Robust processes are established to ensure that young people are only secluded or restrained as a last resort, where all other methods have been exhausted and failed, including documentation of all methods attempted.
  4. Leave restrictions are not placed on voluntary tāngata whai ora.
  5. A dedicated sensory modulation area is available to tāngata whai ora at all times.
  6. Tāngata whai ora are able to make a written complaint independently of staff.
  7. Feedback containing concerns about treatment are categorised as a complaint, and are dealt with accordingly.
  8. Consent to treatment paperwork is completed for all voluntary tāngata whai ora, and where tāngata whai ora have not signed, the reasons for this are recorded.
  9. The DHB ensure maintenance and repair work be urgently undertaken in the HNU.
  10. The new build is progressed urgently and in line with best practice for the design of mental health facilities.
  11. Resource is available to improve the range of activities and programmes on the Ward, including during evenings and weekends.
  12. Visits take place in a way that protects the privacy of tāngata whai ora.
  13. Tāngata whai ora have access to telephones independently of staff, unless individual assessment deems it unsafe.
  14. Tāngata whai ora receive medical assessment promptly on admission, and if this is not practicable, the reasons why are recorded in case notes.
  15. A systemic review of medication controls and processes is undertaken, and all necessary steps are taken to reduce the number of medication errors.
  16. The DHB ensure staffing is adequate to ensure care for the number of tāngata whai ora on the Ward.
  17. All staff are up-to-date with mandatory training.

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 Ward’s multi-disciplinary and leadership teams, to outline their initial observations.

The Ward, the DHB, and the Ministry of Health received a copy of my provisional report and were invited to comment. I thank them for their feedback, and have had regard to it when preparing my final report.


[1] A person who uses mental health and addiction services. This term is often used interchangeably with service user, consumer or client. Return to text

[2] When the term Inspectors is used, this refers to the inspection team comprising one Senior Inspector and one Inspector. Return to text

[3] MidCentral District Health Board. Ward 21 – Increase of Staffing. April 2021. This business case showed bed day usage at an average of 143% between April 2020 and March 2021. This was consistent with occupancy at the time of inspection. Return to text

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