The Chief Ombudsman has published the full report behind the closure of a Dunedin hospital ward for adults with intellectual disabilities, setting out how one patient spent at least 18 months shut in a bedroom whose door was opened for 90 seconds a day.
The report on Ward 10A and Helensburgh Cottage at Wakari Hospital was released on Thursday 20 August. It draws on visits by the Ombudsman’s inspectors in October last year and over four days in March, carried out under the Crimes of Torture Act 1989. By the time provisional findings were made public in July, Health New Zealand had already closed the ward to new admissions and the Ministry of Health had accepted the Chief Ombudsman’s recommendation that it hold an independent inquiry.
Inspectors described one person who had been locked in their bedroom “almost unceasingly” for at least 18 months, with almost no meaningful human contact and no access to the outdoors. They said they were very concerned that the physical arrangements were increasing that person’s institutionalisation. “We considered these arrangements may amount to prolonged solitary confinement,” the report said. At the time of the March inspection the person’s bedroom door was being unlocked and left open for 90 seconds, which was itself an improvement on the 30 seconds recorded earlier.
The inspectors set out a pattern of practice across the ward that they said went well beyond that one case. RNZ reported that people were incentivised with access to basic necessities, with toilet access restricted during seclusion and dental care made conditional on behaviour settling down. Patients were unable to spend their own money without staff agreement. Sedatives were given, including by intramuscular injection, without apparent consent. Bariatric evacuation mats, designed for moving people in an emergency, were used to restrain a person and caused friction burns.
“We became very concerned about the conditions and treatment experienced by tāngata whaikaha,” the report said, using the term for disabled people. “We were concerned that the practices of the ward were extreme, fostered institutionalisation,” it went on, adding that inspectors were “highly concerned about the potential use of punitive, coercive and unlawful practice”. On seclusion, the report said that in the inspectors’ view moving a disabled person to a seclusion room “is not a ‘legitimate medical reason’”.
Helensburgh Cottage, a facility on the same site intended to help people move from the ward towards living in the community, had sat empty since the pandemic. Inspectors said it appeared to be a better environment in which to provide care, and staff told them it was not being used because of staffing pressures.
The report asks Health New Zealand to end prolonged isolation urgently and improve conditions, to stop using the evacuation mats as restraints, to review every patient’s medication to confirm it is lawfully prescribed, and to put in place a model of care built around wellbeing and rehabilitation rather than containment. It also asks the Ministry of Health to make sure an independent investigation is carried out. When the provisional findings were released in July, the Chief Ombudsman said it was important that the same number of beds remained available across the system so the closure did not put more pressure on it.
When the provisional findings were made public on 3 July, Chief Ombudsman John Allen said he was “disturbed by what our inspectors found”. He added, “What they observed at Ward 10A are some of the worst practices we have observed anywhere,” and said inspectors had found “compelling evidence of punitive and coercive treatment of people in the ward”. He described the findings as “allegations of serious and significant failures that amount to potential human rights abuses”.
Health New Zealand’s board decided in July to close Ward 10A as a forensic intellectual disability unit. Its national director of mental health and addictions, Phil Grady, said at the time that the board “has now made the decision to close Ward 10a”, with patients being moved to settings better suited to them and a national review of forensic intellectual disability services to follow. He also said, “We take patient safety and care very seriously and want to acknowledge the patients, their families, and our staff, all of whom we are supporting during this period of change.” He added that the focus remained “on ensuring the safety, dignity, and rights of the current patients, while strengthening oversight and reviewing practices”.
The separate Ministry of Health inquiry, announced in July under section 101 of the Intellectual Disability (Compulsory Care and Rehabilitation) Act 2003, is being led by Auckland district inspector Andrew Molloy with Wellington consultant clinical psychologist Nigel Fairley. It covers care provided over the two years to June and is due to report six months from when it began. Director of mental health Dr John Crawshaw said the scope “includes considering whether care met legal and clinical standards, whether restrictions on care recipients were justified and proportionate, whether the rights of care recipients were upheld, and whether there are wider systemic issues that require attention”. The inquiry can refer matters to the Health and Disability Commissioner or to police.
Concerns about the ward are not new. A report published in February 2022 by then Chief Ombudsman Peter Boshier, after an unannounced inspection in May 2021, found the ward was not fit for purpose, mixed forensic and non forensic patients and did not separate men and women. Staff working there described the physical environment as “a disgrace”. Many of the shortcomings identified in an earlier inspection in 2014 had still not been fixed.
Advocates reacted angrily when the July findings landed. Patient Voice Aotearoa chairman Malcolm Mulholland told RNZ he thought “it was barbaric, what was happening to patients”, and said he hoped authorities would “undertake a wider look at all psychiatric facilities in New Zealand to ensure that this is not happening to our most vulnerable”. Disability rights lawyer Huhana Hickey said successive governments “over decades have done nothing to find that solution”, particularly for young men who are autistic or intellectually disabled and have behavioural issues. Associate Health Minister Matt Doocey said he expected Health New Zealand “to urgently address the issues that have been identified, not just at Wakari but nationally”.
The ward will close fully once the remaining patients have been relocated. The Ombudsman’s report includes a list of what Health New Zealand and the Ministry of Health have said they will do in response to each concern, and the office has said it will keep watching whether those commitments are met. For families who spent years asking questions about a small unit on a hill above Dunedin, the published report is the first full account of what inspectors actually saw.
What do you think should happen next for people held in units like Ward 10A? Leave a comment below and let us know.
This article was written by AI, briefed to report the facts, hopefully without some of the bias people bring to the job 🙂
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