Conditions uncovered during a visit to Wakari Ward 10a included a patient being secluded in their room for 18 months and others being blocked from using the toilet.
In one instance, a person was tied down on a bariatric or ‘‘EVAC’’ mat to move them around the ward.
Other instances of ill-treatment included restrictions on dental care and people being denied access to their own money.
Chief Ombudsman John Allen has declared the ward totally unfit for purpose and ordered a review into the systems at Wakari in its entirety.
‘‘I think quite clearly the ward as it currently is, is unsuitable for the people who are being housed in it,’’ he told the Otago Daily Times.
‘‘I am disturbed by what our inspectors found. What they observed at Ward 10a are some of the worst practices we have observed anywhere.’’
The way in which that ward had been administered and operated had failed its patients, he said.
‘‘There needs to be an independent review or a review undertaken by the Health Ministry and Health New Zealand to determine exactly why the failings occurred and to address them.’’
Inspectors also noted that treatment of people may have extended to the unlawful administration of medication.
Asked whether it was a failing of the present configuration of the facilities or of the staff, Mr Allen was equivocal.
‘‘That’s why you have an investigation. We need to allow that process to run its course. Obviously with a fair degree of urgency so as to answer exactly those questions.
‘‘I don’t think that the ward as currently operated and as currently configured has a future at all. Whether there is a mechanism for enabling that future is a matter for Health New Zealand to assess.’’
This is not the first time the Office of the Ombudsman has made a notable visit to the hospital.
In 2022, a report for the office by then chief ombudsman Sir Peter Boshier described Ward 10a as not fit for purpose and a ‘‘volatile’’ environment for patients and staff.
Mr Allen said it was disappointing there had been little improvement since then.
‘‘If you read Sir Peter’s report, you will see that many of the criticisms about the facilities ... were spelt out very, very clearly.
‘‘Equally clearly, very little progress has been made in addressing those findings of his and it is imperative that action is taken.
‘‘The facility at the moment simply cannot provide the environment that is necessary to either support or rehabilitate the people who are being committed to it.’’
Mr Allen acknowledged the physical environment of the ward, including the lack of space and light, played a factor in its failings.
‘‘In terms of the practice within the facility, I don’t doubt that the environment makes it very challenging for staff to be able to best support the people who are in there, but there are clearly practice failings in the observations made by our inspectors in what they saw.’’
Mr Allen said they would be actively engaged in monitoring progress and outcomes.
‘‘I would expect to have substantive, ongoing discussions with both Health New Zealand and the Ministry of Health in relation to both of those matters.’’
He did, however, feel something positive came out of the visit and inspection.
‘‘By shining a light on this reality, I think we will get better outcomes for the individuals who are currently within that facility.
‘‘So I’m encouraged by the possibilities that they may be moved to more suitable accommodation where they can be better supported to be rehabilitated into the wider environment.’’
Despite the severity of the observations, ‘‘none of them’’ should have come as a bombshell to officials, Mr Allen said.
‘‘What we do know is that the consequences of the inadequacies of the facility and the practice that was adopted has had a material impact on the patients’ concerns.
‘‘And we know that from observation and from the visits of our inspectorate.’’
‘‘The allegations are deeply disturbing and demand a full response.
‘‘The ombudsman’s language should be a wake-up call. These findings point to systemic failures that cannot be ignored.’’
She said the upcoming review must be genuinely independent, establish exactly what went wrong, why it was allowed to happen, and what changes are needed to ensure it never happens again.
‘‘It must hear directly from patients, families, former staff and advocates, and make recommendations that are acted on.’’
Ms Leary said a good outcome would be lasting cultural and operational change, improved facilities, stronger leadership and governance, better oversight, reduced use of restrictive practices and confidence that the rights of vulnerable people were being protected every day.
‘‘I also want to acknowledge the bravery of patients, former patients, families and current and former staff who have come forward to me over a number of years to share their experiences. Speaking out is not easy, and I am incredibly grateful to them.
‘‘Their courage has helped ensure these issues could not continue to be overlooked.’’
Health New Zealand Te Whatu Ora director of mental health and addictions Phil Grady welcomed the independent investigation by the Ministry of Health into Ward 10a.
On Wednesday, the HNZ board agreed to close Wakari Ward 10a as a forensic intellectual disability (ID) unit, with the future use of the ward yet to be determined.
‘‘Work has begun to close the ward and will be completed once all current patients have been safely relocated to facilities that are better suited to their needs.’’
A wider review of forensic intellectual disability services nationally would also be undertaken in partnership with the services’ funder, the Ministry of Social Development, he said.
‘‘The issues raised by the ombudsman relate to the treatment and conditions experienced by some patients in Ward 10a and include concerns about restrictive practices, prolonged seclusion, rehabilitation opportunities, and aspects of care delivery.
‘‘Health NZ takes these concerns extremely seriously.’’
The inspection, between March 17 and 20, was carried out under the Crimes of Torture Act 1989. It was part of the ombudsman’s role under the Optional Protocol to the Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment.
