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Home / New Zealand

Girl, 11, mistaken as woman: Director of Mental Health launches probe after child restrained, injected with antipsychotics

Benjamin Plummer
By Benjamin Plummer
Multimedia Journalist·NZ Herald·
4 Apr, 2025 06:50 AM5 mins to read

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Prime Minister Christopher Luxon and Police Minister Mark Mitchell on the Health NZ inquiry findings on the detainment of the 11-year-old girl in Hamilton.
  • The Director of Mental Health has launched an independent investigation into a mistaken identity incident in Waikato involving an 11-year-old girl.
  • The child – understood to be autistic and non-verbal – was misidentified as a 21-year-old mental health patient before being handcuffed and injected with antipsychotics.
  • It comes after Health New Zealand acknowledged ‘significant failings’ following a review into the incident.

The Director of Mental Health has launched an independent investigation after an 11-year-old child was restrained at a mental health facility and injected with antipsychotic drugs in a case of mistaken identity.

It comes after Health New Zealand – Te Whatu Ora released findings and recommendations following a review into the incident – first reported by the Herald – on Wednesday, admitting “significant failings” after the young girl was misidentified as a mental health patient in her 20s.

The probe found she was medicated in Waikato Hospital’s admission area on March 9 before being transferred to the intensive psychiatric care unit. She declined oral medications, so staff twice injected her with a medication that is “rarely administered to children”.

“Staff were working on the assumption that they were administering medication to an adult, not a child ... The medication is not first line choice in adults but was given due to a shortage of supply,” the report said.

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It is understood the young girl is autistic and non-verbal, which prevented her from communicating with police and hospital staff.

Now, the Herald understands the Ministry of Health’s (MoH) Director of Mental Health, Dr John Crawshaw, has launched his own investigation into the incident.

The young girl, who the Herald understands is autistic and non-verbal, was injected with two doses of antipsychotic medication at Henry Bennett Centre at Waikato Hospital. Photo / Michael Craig
The young girl, who the Herald understands is autistic and non-verbal, was injected with two doses of antipsychotic medication at Henry Bennett Centre at Waikato Hospital. Photo / Michael Craig

“I have been notified this afternoon by the Director of Mental Health that under section 95 of the Mental Health Act [he] has found it is necessary to conduct an inquiry into the incident at Waikato involving an 11-year-old girl on March 9,” Mental Health Minister Matt Doocey told the Herald on Friday evening.

The MoH website states a section 95 inquiry can be instigated under the Mental Health Act by the Director of Mental Health where there are concerns of a systemic nature or there is a major incident that requires an independent statutory investigation.

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“I think it is right that the Director of Mental Health is looking at this issue further, along with the Health and Disability Commissioner. Both have statutory independence and will need to consider Health New Zealand’s review carefully,” Doocey said.

“We need to ensure they consider these matters seriously and take any appropriate action. I would not want to prejudice their independent reviews, but I am confident they will take the right courses of action.”

Ministry of Health Director of Mental Health Dr John Crawshaw.
Ministry of Health Director of Mental Health Dr John Crawshaw.

A MoH spokesperson said Crawshaw had finished his analysis of the Health NZ review and was preparing advice for ministers. Health NZ and ministers were notified of his decision today.

“There are remaining steps of the process to be finalised and the Director of Mental Health will not be making public comment until all the subsequent processes have been completed. These will subsequently be made publicly available.”

On Wednesday, Crawshaw said the event “should never have happened” and that it was important to fully understand what took place.

“I have now had Health New Zealand’s findings into the event referred to me, I’m looking at the findings and will be considering whether to use my statutory power to instigate a section 95 inquiry. In doing so, I will consider how this may sit with any other potential investigations,” he said.

Police misidentified young girl as woman in 20s, ‘despite genuine attempts’

Waikato Police also released preliminary findings of an internal district review, saying the matter has been self-referred to the Independent Police Conduct Authority.

Its review found it was “reasonable” for police to place the young girl in handcuffs on arrival at Waikato Hospital “to protect her own safety and the safety of staff”.

It said police misidentified her “despite genuine attempts to confirm her identity”.

Police earlier told the Herald the girl was identified as a missing mental health patient in her 20s after a photo taken of her at the facility was distributed to a list of police staff and subsequently a mental care provider.

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“We acknowledge that the events have been distressing for [the young girl] and their family. Waikato Police have met with the family and apologised for the misidentification.”

Venables said the broader review was still in the information-gathering phase.

Shocking incident that saw girl injected with antipsychotics

Police were called to Fairfield Bridge in Hamilton about 6.40am on March 9 after a person described as a female in her 20s was seen walking in distress.

Police last week told the Herald the 111 caller reported the woman appeared to be intoxicated and that city cameras captured her climbing up the rails of the bridge.

Police were called to the Fairfield Bridge in Hamilton on Sunday, March 9 after a person described as a female in her 20s was seen climbing on to the railings. Photo / NZME
Police were called to the Fairfield Bridge in Hamilton on Sunday, March 9 after a person described as a female in her 20s was seen climbing on to the railings. Photo / NZME

Out of concerns she was suffering from a mental health episode, police took her to Waikato Hospital’s Henry Bennett Centre for assessment, where she was handcuffed and later injected with two doses of what the Herald understands was haloperidol, an antipsychotic medicine.

About 6pm – some 12 hours after police responded to the bridge incident – a woman reported to police that her 11-year-old daughter was missing.

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Doocey last week called the incident “hugely concerning” and said, “it might be unprecedented”.

“It does defy belief ... I still don’t understand how an 11-year-old has been confused for a lady in her 20s.

“It’s every parent’s worst nightmare and that’s why I’ve sought assurance of the welfare of the 11-year-old, I’ve been given that assurance that she is doing well.”

Benjamin Plummer is an Auckland-based reporter who covers breaking news. He has worked for the Herald since 2022.

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