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Report on an unannounced inspection of Ward 6C, Dunedin 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 patients detained in secure units within New Zealand hospitals.

Between 4 and 7 May 2021, Inspectors[1]  — whom I have authorised to carry out visits to places of detention under COTA on my behalf — made an unannounced inspection of Ward 6C, which is located in the grounds of Dunedin Hospital in the Southern District Health Board region.  

Summary of findings

My findings are:

  • staff engaged respectfully with patients;
  • whānau[2] of patients were warmly received and provided with updates on any change in their whānau member’s treatment; and
  • the detention status of each patient was recorded.

The issues that need addressing are:

  • whānau were unable to ‘take in’[3] information during their whānau member’s admission process, reducing their ability to remember what services their whānau member had been offered;
  • provision of an admission pack about the Ward to whānau was inconsistent – some whānau had been provided with a pack, while others had not;
  • whānau were unsure what ‘voluntary status’ meant; and
  • access to fresh air and sunlight for patients was restricted.


I recommend that:

  1. On admission to the Ward, patients and their whānau are welcomed appropriately, and provided with relevant information in various forms (electronic, physical, and verbal) at appropriate times to support their understanding.
  2. The Ward ensures its complaints system is accessible and well communicated, includes the centralised recording of complaints, the corrective action taken, and a clear pathway of escalation.
  3. The Ward installs a permanent, clearly identifiable suggestions box that is easily accessible to patients and their whānau.
  4. The Ward puts in place processes to enable voluntary patients to leave the Ward freely and safely, and informs patients of the processes.
  5. Each day patients are provided with the opportunity to leave the Ward, escorted where necessary, including to access an outdoor area that provides space for social interaction, engaging with the natural environment, exercise, and relaxation.
  6. The Ward ensures it has sufficient staff to enable patients to spend time outdoors daily.


Follow up inspections will be made at future dates to monitor implementation of my recommendations.

Feedback meeting

On completion of the inspection, my Inspectors met with representatives of the Southern District Health Board and the Ward’s leadership team, to summarise their initial observations.




[1]     When the term Inspectors is used, it refers to the inspection team that included the OPCAT Manager, Senior Inspectors, and Inspectors.

[2]     This document refers to whānau rather than family. In Te Ao Māori, whānau encompasses family in the fullest meaning. Whānau may include immediate and extended family, whakapapa (genealogy), as well as all persons connected by emotional or spiritual bonds. Any person who has been involved in the care or welfare of a patient may also be considered whānau (kaupapa whānau).

[3]     When asked, whānau spoken to said they could not always recall the information they had been provided with on admission.

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