Patients at an overcrowded Hamilton mental health facility have been subjected to degrading treatment, including extensive seclusion, according to a scathing report by the Chief Ombudsman.
Peter Boshier has called on the Waikato District Health Board to address overcrowding and the high use of seclusion and physical restraints at the Henry Rongomau Bennett Centre [HRBC] at Waikato Hospital.
But the DHB said it had opened extra bedrooms to reduce the overcrowding and reviewed seclusion on a daily basis.
It comes just days after the Herald revealed a roll call of shame at the centre involving murders, suicides or suspected suicides and escape of patients, spanning two decades.
"I consider there is an urgent need to deal with the issues I have raised," Boshier said after releasing the reports to Parliament on Thursday.
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The four reports followed unannounced inspections of the centre in September 2019.
The inspections focused on Wards 34, 35, 36, and the Awhi-rua, Puna Maatai and Puna Poipoi wards which provide a range of sub-acute, acute, forensic, and rehabilitative, inpatient mental health services for 88 adults from the Waikato, Lakes, Taranaki, and Bay of Plenty regions.
Boshier said the treatment and conditions of patients in three out of the four wards inspected were degrading as the result of overcrowding.
It breached Article 16 of the United Nations Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment.
"I believe the current situation at the acute mental health service (Wards 34, 35, 36) is untenable.
"At the time of inspection, the three wards were at 130 per cent capacity.
"Inappropriate placements of service users, high use of seclusion and restraint, lack of privacy, blanket restrictions, compromised care, and limited opportunity for recovery are indicators of a facility in crisis."
Last week four families wrote to Prime Minister Jacinda Ardern and Minister of Health David Clark requesting an urgent investigation into the HRBC after their loved ones died tragically or escaped from the centre.
Jane Stevens, mother of Nicky Stevens - who died while under the centre's care in 2015 - said Boshier's report was a relief, but she asked who would monitor whether the necessary changes were made.
"People are dying as a result of this. This is the train wreck that everybody could see coming.
"We're not seeing the leadership and the commitment to making the changes that need to happen."
Boshier said while there were plans to address overcrowding, and reduce the use of seclusion and restraint, this was not the first time he had raised concerns with the DHB.
"I've had to repeat recommendations made during earlier inspections which is of concern."
In Puna Maatai Forensic Inpatient Ward, there had been a significant increase in the use of seclusion in recent years, particularly for Māori service users.
"There were discrepancies in the collection and reporting of seclusion and restraint data, training on the use of mechanical restraints did not appear to comply with policy, and the relevant restraint policies themselves were out of date," Boshier said.
"I consider that the ward should guard against treating the use of mechanical restraint as normal practice by regularly monitoring and reviewing its use.
"In Puna Awhi-rua, my inspectors found evidence of a service user placed in seclusion for 16 weeks following an assault on a staff member."
The records however did not support the prolonged period of seclusion and, in these circumstances, was degrading treatment, he said.
Boshier was also concerned at the regular use of a practice described by staff as "sleepovers".
This was where people were transferred from one ward to another to relieve pressure on staffing or space.
Patients were observed on sleepovers in wards for days at a time because acute wards were too full.
Communal areas, day rooms and offices were being used as bedrooms.
"Installing curtains and partial walls in the shared bedrooms of Wards 34, 35, and 36, did not provide enough privacy, and service users also reported not feeling safe," Boshier said.
Staff burnout was also a concern on Puna Maatai, due to overcrowding, lack of resources, and the high and complex needs of service users from the courts and prisons, and patients with intellectual disabilities.
While other wards were generally clean and tidy, he described the Puna Poipoi Forensic Rehabilitation Ward as not fit-for-purpose; bedrooms were small with inadequate storage and no ventilation, and there weren't enough showers and toilets.
This is the first time Boshier has released reports into the conditions and treatment of people held in New Zealand's public health and disability facilities.
The DHB said in a statement its mental health service would never turn away a patient who presented with severe need.
"Over the past six months the DHB has opened seven additional bedrooms and has contracted a community provider to accommodate an additional 10 bedrooms."
This had reduced occupancy to closer to 100 per cent, it said.
The DHB said the Government's recently announced $100 million building to replace the HRBC, due to open in 2023, couple with initiatives to increase community care, was expected to deliver benefits for the community and staff.
Addressing the criticism over seclusion and restraint, the DHB said physical restraint referred in most cases to bandages used to restrict movement to prevent the person repeatedly harming themselves.
"There have been an increased number of patients with acute and complex needs, often complicated by the use of methamphetamine and other synthetic agents, who unfortunately are more likely to attempt self-harm or attempt to harm others."
It said seclusion was only used when there were clear and identified risks to patients and staff.
"Prolonged seclusion is a significant concern to us and is reviewed on a daily basis by the clinical team."