Desperately-needed changes to mental health services prompted by failings in the care of a patient with complex needs, have yet to be implemented.
Instead the recommendations from a damning inquiry that made more than 100 findings highlighted by the patient's treatment, are still being worked through by various Government agencies across the country.
In mid-June the Weekend Herald revealed details of a leaked report stemming from the six-month inquiry under the Mental Health Act, which was largely critical of the care provided to the patient.
The case is so sensitive this newspaper is not publishing any details that could identify the patient.
But it was known about by high-ranking officials including then Minister of Health Dr Jonathan Coleman.
The report revealed a catalogue of failings and made more than 100 findings that have "significant implications" for other patients.
"There was no long-term care or responsibility taken by any of the specialist child and adolescent psychiatrists, clinical teams or caregivers, beyond their specific facilities," the report said.
Though some specialists and institutions were praised for their efforts, none treated the patient properly for what was thought to be the root cause of the problems.
The Weekend Herald cannot outline those causes because of legal reasons.
The inquiry found "serious shortcomings" in the services provided to the patient and made findings relating to continuity and consistency of care; clinical decision-making; clinical assessment, diagnosis and formulation; discharge and transfer planning; care and relapse prevention; communication between clinical teams; and Child, Youth and Family placement decisions.
Its recommendations included the need for:
• Changes to inpatient service provision to behaviourally disordered young people with high and complex needs;
• Community placements for these young people;
• Clinicians to use phenomenological criteria [perceptions, emotions and judgements] when assessing a person's suitability for assessment and treatment under the Mental Health Act;
• Assessments made from a longitudinal perspective for better management strategies;
• Clinicians in DHBs across the country to be able to access patient clinical records including mental health records;
• To assertively treat trauma.
The inquiry was ordered by the Ministry of Health's director of Mental Health and Addiction Services, Dr John Crawshaw.
In a letter attached to the report he expressed concern over the patient's treatment, which was brought to his attention by district inspectors of mental health - lawyers advocating for patient rights.
"After careful consideration I have formally accepted the inquiry's findings and recommendations, some of which have significant implications for mental health services nationally," he wrote.
This week Crawshaw answered questions on action taken since the report's release more than a year ago.
"Agencies have responded well to the report, and are working toward implementing the recommendations," he said.
"I am satisfied with the progress in implementing recommendations and confident agencies are treating them with the seriousness they deserve."
Crawshaw said the Ministry had an ongoing function to monitor the progress of issues raised in the course of the inquiry, with the long-term actions still ongoing.
"I correspond regularly with agencies on their progress implementing the recommendations."
It's understood the report has been released to the district health boards involved in the case.
Crawshaw would not say if the patient was still receiving treatment because of privacy issues and a court order outlining rules around publication of the report.
When asked if the report would be shared with the panel undertaking a national mental health inquiry, Crawshaw said the Ministry would comply with its obligations under the Inquiries Act.
Crawshaw confirmed current Minister of Health, Dr David Clark, had been advised of the report.
Clark said it was not appropriate for him to comment on the details of "this very unfortunate and sad individual case".
"What is important is that situations such as this are properly investigated and any lessons are learnt for the future," he said.
"I am assured by the Ministry that is exactly what is happening in this instance."
Oranga Tamariki - Ministry for Children care support general manager, Paula Attrill, said since the report was released, Oranga Tamariki had been working with the Ministry of Health to identify where improvements could be made.
"We are currently developing a work programme with the Ministry of Health that will respond to the recommendations in the report which are relevant to Oranga Tamariki."
Last April international human rights expert Dr Sharon Shalev slammed New Zealand for having high seclusion rates among prisoners, children, mentally unwell and the intellectually disabled.
In 2016 a separate Herald investigation revealed the plight of Ashley Peacock, an intellectually disabled, autistic and mentally ill man who was kept in a tiny wing of the Tawhirimatea mental health unit at Porirua for five years, allowed outside for an average of 90 minutes a day.
The investigation prompted an agreement to free him but he remains at the unit.
Editorial: Failings need to be exposed
The Weekend Herald battled for seven months to report the impact on healthcare across the country following a secret report detailing serious failings in the treatment of a mental health patient.
This is a case where the public interest and patient privacy are finely balanced.
After a lengthy legal fight there is still a vast amount of detail we cannot go into.
But make no mistake — while we cannot report details of the patient's treatment, it is an appalling catalogue of failings over a long time involving a lot of people.
Seasoned editorial staff were horrified by much of the detail and, in particular, the ongoing failure to resolve the issues.
The report went to the very top — to the Minister of Health at the time and the head of mental health for the ministry.
It contained more than 100 findings that will shape mental health care across the country.
The Ministry of Health sought a court injunction to block the Weekend Herald from reporting many details — an injunction granted without the Herald having the opportunity to make submissions.
That is an assault on the transparency that is crucial if we are to maintain trust in a government organisation tasked with looking after some of our most vulnerable people.
We were eventually able to publish a sanitised summary of the report after litigation was resolved.
Yet today, more than a year after the report was written and a month after we published our first story, we find that many of the changes recommended have still not been implemented.
Protection of the patient is paramount and the Weekend Herald supports that — but it should not be used as a shield to protect those responsible.
The ministry tell us agencies are working through the recommendations. It is our duty to be watching.