A highly critical Ombudsman's report into a Whanganui mental health facility is calling for urgent recognition and remedy of disproportionate use of seclusion for Māori.
Chief Ombudsman Peter Boshier says urgent action must be taken to ensure the humane and equitable treatment of Māori at the acute mental health unit where 90 per cent of seclusion in the six-month review period applied to Māori.
• Read more: Report details excessive seclusion, overdoses
He said Māori were disproportionately represented by the use of seclusion and the hours spent in seclusion.
Sometimes seclusion facilities were used at the neighbouring long-stay rehabilitation unit Stanford House. These were "not fit-for-purpose" and should not have been used to seclude patients, Boshier said.
He was concerned not all seclusion events were being recorded; inspectors noted at least two events meeting the definition of seclusion were not noted.
Seclusion is defined under the Mental Health (Compulsory Assessment and Treatment) Act 1992 as being "where a person is placed alone in a room or area, at any time and for any duration, from which they cannot freely exit".
In the report released this week following an unannounced four-day inspection of Whanganui Hospital's 12-bed unit Te Awhina, Boshier said he was concerned at a 60 per cent increase in the use of seclusion.
Data from the six months before the inspection in September last year showed 844.5 hours of seclusion were recorded, up from 513 hours in the six-months preceding the previous inspection in 2017.
The tally included "seclusion events" and "night safety orders" for overnight seclusion.
"There's been a lot of seclusion here," Boshier told Local Democracy Reporting.
"With a mental health facility such as this, in terms of Te Tiriti o Waitangi, I'm concerned that there should be provision for Māori which is appropriate."
The report said two-thirds of secluded patients were Māori, and their time in seclusion constituted almost 90 per cent of the unit's total seclusion hours in the period reviewed.
By contrast, Māori made up about 46 per cent of tāngata whai ora (patients) at the unit during that period.
"I acknowledge that a sample size of 10 seclusion events means that the acuity and risk of one or two tāngata whai ora can have a sizeable impact on the data," Boshier said.
"Nevertheless, to ensure the humane and equitable treatment of Māori and to act consistently with the principles of te Tiriti o Waitangi, it is necessary to recognise and remedy the disproportionality as a matter of urgency."
The report said although seclusion paperwork was routinely completed, there was little evidence of de-escalation attempts or the use or consideration of alternatives to seclusion.
Seclusion reviews were often light on detail and did not evidence the need for patients to remain in seclusion, and it did not appear that those secluded overnight were robustly assessed to determine whether they could exit seclusion.
While night safety orders had been eliminated shortly before the inspection, staff told inspectors a patient had been locked in a bedroom overnight without observation and outside of seclusion protocols in the week before the inspection.
This event was not recorded as seclusion despite meeting the definition.
Boshier said he was also "seriously concerned" to hear about the involvement of a security guard in one seclusion event in which the guard directly interacted with the patient, including verbally directing the patient.
Staff told inspectors that the unit occasionally used security guards to help them feel safe when staffing levels were low and when there were highly acute patients in the unit.
"Tāngata whai ora in seclusion are highly vulnerable. Where seclusion is necessary, only appropriately trained staff should interact with tāngata whai ora," Boshier said.
He also reported serious concern at a high number of medication errors.
There were 23 reported medication errors including missed medication or overdoses.
Boshier made 14 recommendations for change following the inspection, 11 of which Te Awhina accepted outright.
Te Awhina clinical nurse manager Peter Skilton said seclusion had been used only once in the 11 months since the inspection.
He said alternatives to seclusion and in particular a new approach to Māori patients was being implemented.
"We are aiming at a new culture within the unit – transformational change. Seclusion is a very rare event now."
Although neighbouring Stanford House had historically provided beds or seclusion beds when Te Awhina was full, no patients had been secluded there for many months.
Skilton said periodic over-occupancy was a national issue for mental health facilities.
"I don't believe there was any expectation that we would have this level of demand on mental health services.
"There's no question that at 12 beds we are achieving 230 per cent occupancy at times when peaks are very, very high."
In the first six months of the year, Te Awhina had been over occupancy eight times, he said.
During these periods, patients were placed temporarily in whānau areas, common rooms and other emergency-use spaces.
Whanganui District Health Board said significant work had been done since the inspection, addressing issues raised in the report.
No security guards have been used since the inspection and a major project has been undertaken on medication safety.
"The DHB is fully committed to the wellbeing of those in our community who need these services and to ensuring the best outcomes for their health now and into the future."