A new report has put forward a raft of recommendations to improve Hutt Valley District Health Boards Mental Health Service.
It follows an investigation after serious allegations about the service were made in 2010.
The Director of Mental Health Dr John Crawshaw says the inquiry found flaws in statutory duties, including management, monitoring and reporting of serious incidents.
But Dr Crawshaw says the investigation has led to important changes in services.
The Ministry of Health will monitor the DHBs implementation of the recommendations.