Report details excessive seclusion, overdoses at Whanganui's Te Awhina mental health facility

A report into Whanganui's Te Awhina Acute Mental Health Facility has found a significant number of failings, including growing use of seclusion and a significant number of incidents involving incorrect or excessive medication being supplied to patients.

The report, by Chief Ombudsman Peter Boshier, was released to the public this afternoon.

It made 14 recommendations to the Whanganui District Health Board, ranging from refurbishing parts of the unit to putting in place a plan to reduce medication errors.

The board accepted 11 of the recommendations, and partially accepted three, but also told the Chronicle "the report is historical and does not reflect what is currently happening". The DHB said significant work had been done since the inspection the report was based on.

Te Awhina, a 12-bed unit on the grounds of Whanganui Hospital, treats patients "in the acute phase of their mental illness when they would typically find it hard to deal with at home", the board says.

Patients are treated either voluntarily or compulsorily under the Mental Health (Compulsory Assessment and Treatment) Act.

The facility has a history of serious assaults and overcrowding. Photo / File

The report was done under the United Nations' Optional Protocol to the Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment (OPCAT).

New Zealand's ratification of that protocol requires regular inspection of places of detention, and reports on the treatment and conditions of those held within them.

The report said seclusion had become a growing issue at Te Awhina, with a 60 per cent increase in total seclusion hours since the previous OPCAT inspection in 2017.

In the six months leading up to the inspection between March 1 and August 31 last year, 10 seclusions involving six patients were recorded.

It was also noted that within the six months, 90 per cent of those secluded were Māori.

The proportion of Māori patients in the unit varied between about 36 per cent in March to about 60 per cent in September.

The report also revealed periods of seclusion that were not recorded by staff, including an incident witnessed by inspectors themselves, in which a patient was left locked in the seclusion room.

It concluded that more action was needed to reduce and eliminate the use of seclusion in the unit, with a particular focus on equitable treatment of Māori.

The report also recorded 23 medication errors in the six months leading up to the inspection, which the Ombudsman said he was "seriously concerned" to see.

According to the report, there was a clear pattern of documentation errors, which often led to missed medication or, in some cases, overdoses.

Reports from as early as May last year indicated that the unit had identified a systemic problem with medication errors, but details on preventive measures were limited and the same errors were repeated in the following months.

Te Awhina acute mental health facility is designed to accommodate a maximum of 12 patients at any given time. Photo / File

Records showed one review after an error was made recommended keeping all medication charts in the medication room. However, inspectors observed that medication charts were left lying around the nursing station.

One medication chart went missing during the inspection, the report said.

As well as concerns around seclusion and medication, the report also found that the unit's complaints process was lacking, with no information about the process on display at the unit, nor any complaints forms available.

One patient laid a complaint in the six months before the inspection but did not get a written response as required under the complaints policy.

The report also stated that, short of some concerns about a "Pākehā-centric" model of care, whānau were impressed with the level of care patients received.

The report praised the unit's cultural and spiritual support, the quality and quantity of food, and staffing levels and retention.

Meanwhile, a report also released today into the Stanford House addiction facility, next to Te Awhina, said it was an example of best practice.

"This report provides a rare example of comprehensive best practice and demonstrates what can be achieved with existing resources. Publication of this report will give other comparable facilities a description of best practice which may be emulated," Boshier said.

There were no recorded instances of seclusion or restraint at the facility, and the report made no recommendations to the DHB.

In a statement, a Whanganui DHB spokesman said while they acknowledged the report on Te Awhina, significant work had taken place since the original inspection.

"The reports follow an inspection in September 2020 and since that time significant work has been done at Te Awhina, addressing issues raised in the report. In that respect the report is historical and does not reflect what is currently happening," the spokesman said.

"The outcomes have been positive with seclusion rates dropping to a single case this year. Room issues have also been addressed with the purchase of new purpose-made furniture at an approximate cost of $10,000."

The facility had also invested in an upgrade to the destimulation and exercise rooms, and a "major project" was undertaken in relation to medication safety.

"Whanganui DHB has an experienced and pro-active team dedicated to the provision of first-class mental health facilities and services. The DHB is fully committed to the wellbeing of those in our community who need these services and to ensuring the best outcomes for their health now and into the future."

In January the Chronicle revealed the facility was significantly overcrowded at times last year, with some patients having to sleep on mattresses on the floor, which Health Minister Andrew Little said was "never acceptable".

In 2018 the Chronicle reported that staff at the facility had been head-butted, spat at, punched and one had been sexually assaulted.

Full list of recommendations:

Partially accepted by the DHB

• The destimulation room in Kiwi wing is not used as a bedroom.
• The unit never seclude tāngata whai ora (patients) in Stanford House.
• Tāngata whai ora are able to control the level of natural light in their bedrooms independently of staff.

Fully accepted by the DHB

• The high and increasing use of seclusion is addressed with a particular focus on equitable treatment of Māori.
• The unit ensures that all events that meet the definition of seclusion are recorded as such.
• Security guards are never involved in the care of tāngata whai ora.
• The furnishings and light fittings in the Sensory Modulation Room are replaced or upgraded.
• The complaints process, including complaint forms, are well advertised and accessible to tāngata whai ora on the unit and their whānau.
• Duly authorised officers complete detaining paperwork with their name.
• Rooms without external window coverings are not used as bedrooms.
• The privacy of tāngata whai ora in the Kererū wing is improved.
• More resources and supervision are available for programmes and activities on the unit.
• Tāngata whai ora receive timely physical examination on admission. If the examination cannot happen, the reasons and a plan for it to occur, are documented in the clinical file.
• The DHB put in a plan to significantly reduce the number of medication errors.