• More than 60 reports into mental health and disability units released to Herald following investigation into the care of Ashley Peacock.
• He is one of four cases which could be considered 'cruel, inhuman or degrading' in secure units at New Zealand hospitals.
• Inspectors found other repeated examples of poor care, including overcrowding and untrained staff. Some patients did not have access to fresh air or water.
• The Chief Ombudsman is 'sufficiently concerned' to consider launching a special inquiry.

Elderly, mentally ill patients were subjected to the "prolonged and excessive" use of restraint belts at a secure hospital unit - one of the potential human rights breaches uncovered by torture inspectors.

A Herald investigation has analysed more than 60 Crimes of Torture Act reports written about health and disability detention sites across New Zealand and will make them public for the first time.

District health boards supplied the documents under the Official Information Act following a Herald investigation into the treatment of autistic man Ashley Peacock, who was held in prolonged seclusion at a mental health unit in Porirua, despite inspectors warning the conditions were "cruel, inhuman or degrading".


The reports detail three other cases at that level - each arguably a breach of our international human rights obligations - as well as dozens of other examples of poor quality care at the 50 sites examined since 2010.

The Human Rights Commission and the Office of the Ombudsman believe the findings highlight systemic issues, including the continued dominance of "punitive" treatment instead of a therapeutic approach.

This assertion was "strongly refuted" by the Director of Mental Health, Dr John Crawshaw, who said there was ample evidence of a "recovery" approach being applied in mental health service.

"A commitment to and a belief in people's recovery and wellbeing is at the heart of mental health clinicians' practice," he said.

Ashley Peacock, while out for a walk near Porirua's Regional Rehabilitation Unit Tawhirimatea. Photo / Mark Mitchell
Ashley Peacock, while out for a walk near Porirua's Regional Rehabilitation Unit Tawhirimatea. Photo / Mark Mitchell

The reports are written by specialised inspectors who make unannounced visits to mental health and disability wards, dementia units and forensic hospitals.

Copies of each report are sent to the area directors of mental health, the Ministry of Health and the minister. The ministry follows up on each report by seeking information about how recommendations are being addressed. However, the reports are only made public if the health boards decide to publish them.

App users click here to read the Torture Act reports

Analysis of the documents back to 2010 found the same issues cropped up repeatedly: the inappropriate and ongoing use of seclusion and restraint; overcrowding; untrained staff; unsafe, rundown or not fit-for-purpose facilities; and a lack of proper documentation about the detention of patients.


A handful of sites failed basic tests such as patient access to fresh air, water, or meaningful activities.

While some places were bright, airy and modern, others were described as "gloomy", or "depressingly grim", particularly when referring to the high-needs or seclusion (solitary confinement) areas.

During the six years covered, inspectors made hundreds of recommendations to improve conditions. However, in some cases they returned to find the issues persisted.

Last year, a joint report between the Human Rights Commission and the Ombudsman urged the Government to include the sites in its mental health planning and development, saying it first raised issues about staffing issues in 2007, to no avail.

Chief Ombudsman Peter Boshier said his office was still "sufficiently concerned" about the treatment of detainees who have high mental health issues and needs and he was considering a special investigation.

Shaun Robinson, the chief executive of the Mental Health Foundation, was "extremely concerned" to hear vulnerable people were being treated so poorly in hospitals.

A spokeswoman for Health Minister Jonathan Coleman said the reports are sent to his office, the DHB concerned and the Director of Mental Health. "It's my expectation that the DHB and the Director of Mental Health follow up accordingly."

Green Party health spokesman Kevin Hague said he was floored by the extent of the "disgusting and shameful" practices in the reports.

The torture reports

Among the torture reports were four examples where treatment of patients could be considered cruel, inhuman and degrading. The first was the case of Ashley Peacock, who was held in prolonged isolation. The others were:

• Star 1 in Palmerston North, a 15-bed elder care ward run by the Mid Central District Health Board, where patients were being subjected to prolonged and excessive use of mechanical restraints, specifically having a device called a "T-Belt" used on them for up to four hours at a time.

The DHB did not agree its treatment was cruel, inhuman or degrading, and while it tried to minimise the use of restraints, "from time to time a particular patient may necessitate judicious use of restraint".

• Waiatarau Mental Health Inpatient Unit, a 32-bed recovery-centred facility run by the Waitemata District Health Board, where a recent decision to lock the ward meant at least one non-compulsory client was being arbitrarily detained, and other clients were unable to access fresh air throughout the day.

Waitemata DHB said it had acknowledged the findings and was "working to enhance patient access" to the outdoors.

• Te Whare Maiangiangi, a 20-bed acute mental health ward in the Bay of Plenty, where seclusion rooms and day rooms were being used as bedrooms due to overcrowding.

Bay of Plenty DHB did not respond.