• 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.
• District Health Boards have responded to the reports

A Herald investigation has analysed more than 60 Crimes of Torture Act reports written about health and disability detention sites across New Zealand and made 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".

Below are details of some of the reports, and corresponding responses from the District Health Boards where inspectors highlighted serious issues or made strong recommendations.


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.

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.

Read more from the reports, below:

STAR 1 (Elderhealth), Mid Central District Health Board, December 2015

There was evidence of patients being arbitrarily detained; and patients were being subjected to prolonged and excessive use of mechanical restraints which could be seen as cruel, inhuman or degrading

Inspectors said the site needed a reduction policy to reduce restraint use. In 2015, there were 582 incidents involving the use of a "T-belt", largely when patients displayed "agitation, violence, and aggression". The belt was used from 5 minutes to over four hours. One patient accounted for 433 incidents.

While the minimum period for checks for patients undergoing a period of restraint was two hourly; inspectors were concerned, there were no guidelines relating to maintaining fluid intake and toileting requirements during the restraint period.

They also said paperwork on the unit was poor. Some restraint reports had no start or finish time. Other patients did not have the necessary paperwork to be detained, an issue raised in 2012.

Inspectors said patients had limited access to purposeful activities and programmes, and that the Secure Care Unit within the ward was poorly designed and not fit-for-purpose. There was limited communal space available in the SCU "which could be a contributing factor to the high number of restraint incidents", the report said.

Response: Mid Central DHB

MidCentral DHB does not agree that its use of restraint or the care it provided was cruel, inhuman and degrading. It is important to note that the inspectors considered "it could be seen" rather than "it was".

MidCentral DHB endeavours to minimise the use of restraint of this type, but from time to time a particular patient/s may necessitate judicious use of restraint. Indeed, the records reviewed during the audit relate mainly to the specific circumstances and challenging behaviour of a small number of patients, which is now historical as the care provided and use of restraint in these circumstances had ceased by the time of the ombudsman's site visit.

The use of restraint at the time of the audit site visit had reduced to the level of activity that would be consistent with rest home care of people with dementia and occasional agitated behaviour.

We support the Ombudsman's insights regarding the legal basis for detaining patients in Star One and have made improvements. Previously, patients, such as those with dementia, were on occasion detained under the clinical responsibility of duty of care in order to prevent them putting themselves at risk, ie, wandering into heavy traffic areas. This situation has been addressed and all patients who may be detained have a more formal legal basis determined to support this intervention.

The lack of necessary paperwork relates to determining a more formal basis for detaining a patient (for instance in the SCU area) and all required documentation is now in place.

The Star Unit is over 20 years of age and we agree aspects of it are no longer fit for purpose. The design of Star One's Secure Care Unit has been reviewed and an internal report on issues and possible solutions is being developed by the Mental Health and Addictions Services.

Waiatarau Mental Health Inpatient Unit, Waitemata District Health Board, February 2016

There was evidence of an informal client being arbitrarily detained; which could be seen as cruel, inhuman or degrading treatment or punishment of patients for the purpose of the Convention Against Torture.

"At the time of our last inspection (2012), Kereru (IPC) was a locked facility and Pukeho and Takahe were both open. As a result of several clients going AWOL (absent without leave), the Unit is now locked. This is disappointing and not in keeping with the basic values of a recovery centred service. There was one informal client (not under the MHA) being arbitrarily detained in the Unit (he had no approved leave and was unable to exit the Unit) at the time of the inspection. This is not acceptable."

"Clients reported their frustration at not being able to access fresh air throughout the day. Several next of kin expressed concerns about the lack of open space in the Unit and the current restrictions on access to fresh air."

"Due to the significant difference between the Unit and electronic registers, the Inspectors were not confident that the use of restraints was being accurately captured"

Response: Dr Murray Patton, Clinical Director Mental Health Services, Waitemata DHB

There were some recommendations for further improvement which we have welcomed and either already implemented or are actively working on.

The audit of the Waiatarau unit recommended the practice of locking‐in informal patients should end. The DHB has acknowledged this recommendation. The service facilitates informal patients to egress the locked doors on request and is working to enhance patient access to outdoor areas.

Te Whare Maiangiangi, Bay of Plenty District Health Board, March 2014

"On the day of the visit there were three service users being accommodated in the seclusion rooms who were not under a seclusion regime and one patient being housed in the admissions/day room (eight service users in total). Additionally, there were four patients in the IPC ( Intensive Psychiatric Care unit).

Housing eight acutely unwell service users in such a confined space is not only distressing for the service user but unsafe for everyone living and working in there. I am concerned that the seclusion rooms and admissions/day room is being used to accommodate (bedrooms) service users on a regular basis which could potentially amount to cruel and inhuman treatment."

Bay of Plenty DHB did not reply to questions.
App users click here to read the Torture Act reports

Ward 21 - Acute Inpatient Unit , Mid Central District Health Board, December 2015

"The High Needs Unit is depressingly grim with no natural light and minimal furnishing. The small TV lounge doubles as a dining area with clients having to eat their meals on their knees. The quality of seclusion documentation review during the visit was poor. The register was incomplete and relevant incidents not properly documented. The inspectors were not able to analyse the seclusion data at the time of the visit due to missing information. The quality of the documentation relating to restraints was similar. "

"The inspectors found evidence that mechanical restraints (legs, wrists and chest restraints) had been used to restrain one client. They were assured that the practice had ceased. At least one seclusion incident was not registered. The inspectors strongly support the development of a purpose-built facility and understand that there are currently two projects under discussion."

Response: Mid Central DHB

An internal audit of restraint and seclusion documentation was completed and found all episodes of restraint and seclusion had been documented. The access to current records is being updated as some records are retained in an electronic database and may not have been as easily accessible as hard copies of documentation as was the case at the time of the site audit.

We are aware of the issues relating to [the building]. A number of changes have been implemented to improve the dining area, with additional dining tables and a breakfast bar space added. Ongoing work is underway to improve the environment, both to better interior 'feel' and to reconfigure parts of the building, and our consumer advisors are closely involved. The observations about the HNU area are accepted and an internal review and report recommending options for redesign or rebuild has already been developed. This is now being considered.

The observations [about limited activities and space] are consistent with observations we made in our internal review of the original ward layout. Improvements in the activity programme have been made and we are looking at how we can better utilise space for activity. The observation that the spaces available are more limited than we would like in a better design is accepted by the MidCentral District Health Board, and options for redesign of the facility are being considered.
Wahi Oranga, Nelson Marlborough, April 2016

"The seclusion area does not have an outdoor area for clients to access daily fresh air. Given that some clients are in seclusion for several days, this is unacceptable."

"The Unit is being used as a default service for people with a primary intellectual disability diagnosis and/or people who are exhibiting challenging behaviour and who are unable to be managed by Disability Support Services ...unfortunately, because there are no inpatient beds in the Nelson/Marlborough region for the management of acutely disturbed intellectually or developmentally disabled people, they are inappropriately admitted to the Mental Health Inpatient Facility."

"A solution to the current shortage of inpatient beds, and the absence of a specialist, dual diagnosis consultant for people with intellectual disabilities in the Nelson/Marlborough district should be found. "

Response: Chris Fleming, Chief Executive, Nelson Marlborough District Health Board
The original design of the seclusion area included a courtyard but it has been disused because it led to altercations when transferring people to the courtyard. Recommendations for minor modifications to resolve this problem have been made and will be considered alongside the seclusion review which is currently underway.

The service is not used as a default for people with intellectual disability. We indeed have some complex cases for whom we are responsible for their care and we try to place them in the most appropriate facility for their needs. Occasionally we have to use the Mental Health Inpatient Unit but the default position is in fact maintaining these clients in their homes which we support.

Te Puna Waiora, Taranaki District Health Board, 2016

"There is one room located between the adult acute area and the older person's area; it contains a bed and can be accessed from each side of the unit. It was previously used as an office space. Although unoccupied at the time of the inspection, the room is not suitable for use as a bedroom, as it does not afford an appropriate amount of privacy. "

"The IPC, also referred to as low stimulus, is stark and austere. The area looks run-down with chipped paint on the walls and doors, and limited furnishings; which are in poor condition"

"Not all staff were up to date with Control and Restraint training."

"Some service users are being arbitrarily detained in the Unit. Some consent to treatment forms had not been signed. There is no sensory modulation room in the Unit. Service users located in the IPC cannot freely access fresh drinking water and have to ask staff to provide this."

"One service user had been in the IPC since 14 December 2015 and was being managed there mainly due to her threatening behaviour and physically violent outbursts towards others... it was apparent from reading her file notes and speaking with managers and staff on the Unit that she should have been under a specialist service for people with an intellectual disability. Managers, staff and clinicians raised their concerns, not only for this client, but for others currently on the Unit and those that have passed through their doors in recent times, on the inappropriate placement of people with a primary diagnosis of intellectual or developmental disability (with or without a co-existing mental disorder) into the Unit. Not only does this put unnecessary pressure on an already oversubscribed service, the financial pressure is substantial, with funding having to be sourced from within existing budgets."

Response: Gillian Campbell, Taranaki DHB Chief Operations Officer

At Te Puna Waiora's (TPW) most recent visit, in 2016, inspectors found that office space was being used as bedrooms. This room was originally a bedroom. It was then refurbished so it could be used as an office. However, this never eventuated and it has remained a bedroom the entire time.

We understand that prescribing the use of the Mental Health Act to prevent a person leaving is not acceptable practice. When issues, such as this are identified, appropriate actions and learnings are taken and our team is committed to continuous quality improvements to ensure it doesn't happen again.

There is always access to fresh drinking water in TPW. However, in the Intensive Psychiatric Care facility the nearest water point is from a water cooler, situated in the office and therefore water is provided by staff. Te Puna Waiora is undergoing a refurbishment and upgrade this year and this will be resolved.

Training is critical to providing a quality, patient centred service and our TPW staff have full access to a suite of training available, some compulsory and others aimed at professional development. Staff are encouraged and often rostered to attend these training sessions regularly.

We are unable to provide specific information regarding a client's private health treatment. However, we agree there are challenges at times in finding appropriate services in Taranaki for managing a person with severe intellectual disability, and exhibiting behaviours that place themselves or others at harm. Taranaki DHB's multidisciplinary team and a patient's family/whanau will work together to ensure the best care arrangements are made based on an individual's situation.

Full Response: Director of Mental Health, Dr John Crawshaw

The Ministry of Health strongly refutes the assertion that a 'punitive' approach is more prevalent than a therapeutic approach. A commitment to, and a belief in, people's recovery and wellbeing is at the heart of mental health clinicians' practice.

New Zealand's mental health and addictions system is based on a recovery approach, which is evident in the Ministry's service development plan - Rising to The Challenge: The Mental Health and Addiction Service Development Plan 2012 to 2017. Recovery is defined in the national service standards as "the ability to live well in the presence or absence of one's mental illness (or whatever people choose to name their experience)".

There is ample evidence of a recovery approach being applied in our mental health services. As an example of this, in 2014, 93 percent of long-term service users across the country had a relapse prevention plan, up from 59 percent in 2007. A relapse prevention plan identifies a person's early warning signs of a relapse of their condition. It identifies what the person can do for themselves and what their service will do to support them. Ideally, the person will develop their own plan with support from their clinician and their family/whânau.

Seclusion should be used only when there is an imminent risk of danger to the individual or others and no other safe and effective alternative is possible.

Those held in seclusion include some of New Zealand's most difficult and complex cases. Avoiding harm to the patient and respecting their dignity must be balanced with ensuring the safety of those caring for them, and the general public.

Between 1 January and 31 December 2014, 7,091 people spent time in New Zealand adult mental health services (excluding forensic and other regional rehabilitation services). Of these people, 736 (10.4 percent) were secluded at some time during the reporting period.

During the same period, a total of more than 158,000 people engaged with specialist mental health services. (Details are available in the Office of the Director of Mental Health Annual Report 2014).

Reducing, and eventually eliminating, seclusion is one of the goals of Rising to The Challenge.

In keeping with the above goal the Ministry has funded Te Pou, one of the mental health sector workforce development centres, to work with DHBs and the sector to improve service delivery and reduce seclusion events.

Between 2009 - when the seclusion reduction policy was introduced - and 2014, the total number of people secluded in adult inpatient services nationally has decreased by 32 percent. During the same period, the total number of seclusion hours decreased by 55 percent.

The Ministry receives copies of all the Ombudsman's reports on visits of mental health places of detention carried out under the Crimes of Torture Act 1989 (COTA). The Ministry follows up on each of these reports by contacting the service to seek information about how any recommendations are being addressed.

In addition to the COTA inspections by the Ombudsman, there are a number of checks and balances in place to protect the rights of patients under the Mental Health Act. For example, District inspectors are appointed to ensure that the rights of patients receiving treatment under the Act are upheld. District inspectors report monthly on their activities, and any issues of concern, to the Director of Mental Health in Ministry of Health, and to the local DHB Director of Area Mental Health (DAMHS).

Mental health services in New Zealand work hard to help people with high and complex needs, working collaboratively where needs cross two or more areas of health (eg, mental health, addiction and disability).

The Ministry of Health works with other parts of the mental health system to make best use of resources, which may not always be 'bricks-and-mortar' buildings. The Ministry works with District Health Board mental health services and disability support services to develop packages of care across a range of environments for the relatively small group of people that require them.. For some DHBs, this might include long-term rehabilitation for people with high and complex needs. In other cases, the Ministry may need to fund some services (such as disability services) directly to ensure their needs are met.

The Ministry recognises that there is growing pressure on the sector as it works to meet rising demand for mental health services. The Ministry is engaging with the sector on this, and work is underway to better understand these pressures and what is driving them.

The Government has increased mental health and addiction services funding from $1.1 billion in 2008/09 to over $1.4 billion for 2015/16.