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Serious Concerns About Cruel And Inhuman Treatment At Forensic Facility

Chief Ombudsman Peter Boshier says he is seriously concerned about the use of seclusion at forensic units in the Wellington region.

He also says more must be done for an intellectually disabled client who has been living in effective seclusion for years.

Mr Boshier today published four reports following inspections of Haumietiketike intellectual disability forensic unit and three forensic mental health facilities at Capital and Coast District Health Board’s (CCDHB) Rātonga-Rua-O-Porirua Mental Health Campus in July 2020.

The other three reports cover Rangipapa Forensic Acute Mental Health Unit, Tāwhirimātea Forensic Rehabilitation Unit and Pūrehurehu Forensic Acute Mental Health Unit.

"While some of the conditions I have serious concerns about can be attributed to poor design or a lack of investment in infrastructure, others cannot," Mr Boshier says.

The client, named only as Client A in the report of the unannounced inspection of Haumietiketike Unit, was previously identified as living permanently in seclusion in Ombudsman reports in 2014 and 2018.

"In 2014 my predecessor reported on Client A’s living conditions, with recommendations for change. During my inspection in 2017 I found Client A was still living in the same de-escalation bedroom they had been in for about 5-1/2 years," Mr Boshier says.

At the time of the 2020 inspection, Client A was still living in the room and had not had any face to face contact with staff or other clients other than through a wire fence since two staff were assaulted in 2019.

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"I am disappointed that Client A was still living in conditions which I regard as cruel and inhuman treatment and could amount to a breach of Article 16 of the Optional Protocol to the Convention Against Torture (OPCAT)," Mr Boshier says.

Client A was moved to new accommodation in the weeks following the 2020 inspection. Mr Boshier made a follow-up visit in February this year to inspect the new living arrangement and to speak to Client A.

"Their living area was more attractive and spacious, there was an activities room, and the use of a restraint belt means they could have contact with staff.

"However, while I acknowledge the progress made in the care of Client A, they were, as of February, still effectively in seclusion. They remained alone, in a locked area, unable to leave. If they needed to use the bathroom at night, then staff need to be called.

"Client A remained in conditions that are not fit for purpose. While I acknowledge CCDHB considers it is following Ministry of Health guidelines, this treatment clearly meets the definition of seclusion and should be understood as such," Mr Boshier says.

The case is one of a number of concerning issues at units raised in the four reports, including a client who was not medically assessed for nearly 24 hours after sustaining injuries during an intervention, clients sleeping at the ends of hallways and inequitable treatment of female clients at one facility.

"These findings are of immense concern to me and I have again raised my specific concerns directly with the CEO of the DHB. I will continue raising these issues through my inspections and reports with the Ministry of Health and CCDHB," Mr Boshier says.

The inspections were carried out under the Crimes of Torture Act 1989. New Zealand is a signatory to the Optional Protocol to the Convention Against Torture, an international human rights agreement.

Read the reports:

Report on an unannounced inspection of Haumietiketike Unit, Rātonga-Rua-O-Porirua Campus

Report on an unannounced inspection of Pūrehurehu Forensic Acute Mental Health Unit, Rātonga-Rua-O-Porirua Campus

Report on an unannounced inspection of Rangipapa Forensic Acute Mental Health Unit, Rātonga-Rua-O-Porirua Campus

Report on an unannounced inspection of Tāwhirimātea Rehabilitation Unit, Rātonga-Rua-O-Porirua Campus

Editor’s note

New Zealand ratified the United Nations’ Optional Protocol to the Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment in 2007. The Protocol requires States to establish independent National Preventive Mechanisms (NPMs) to regularly inspect places of detention and report on the treatment and conditions of those held within them.

The Chief Ombudsman was originally designated as a National Preventive Mechanism under OPCAT in 2009, which means he monitors treatment and conditions in places of detention designated to him, such as health and disability facilities, to prevent torture and other cruel, inhuman or degrading treatment or punishment.

He can recommend practical improvements to address any risks, poor practices, or systemic problems that could result in a client being treated badly. Follow-up inspections are conducted to look for progress in implementing previous recommendations. Reports are written on what is observed at the time of inspection.

Find out more about the Chief Ombudsman’s role in examining and monitoring places of detention, and read our other OPCAT reports, at

You can also follow us on Facebook: @ombudsmannz or Twitter: @Ombudsman_NZ

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