The Chief Ombudsman has called on the Waikato DHB to address overcrowding and the use of seclusion and physical restraints at its mental health unit, the Henry Rongomau Bennett Centre in Hamilton.
Four reports by Peter Boshier were tabled in Parliament today after unannounced inspections in September last year.
It is the first time the Chief Ombudsman has released reports into the conditions and treatment of people held in New Zealand's public health and disability facilities.
The inspections focused on Wards 34, 35, 36, and the Awhi-rua, Puna Maatai and Puna Poipoi wards which provide a range of sub-acute, acute, forensic, and rehabilitative, inpatient mental health services for 88 adults from Waikato, Lakes, Taranaki, and Bay of Plenty regions.
Boshier found the treatment and conditions in three out of four wards inspected were degrading and the result of overcrowding.
He said the treatment breached article 16 of the United Nations Convention against Torture and Other Cruel, Inhumane or Degrading Treatment or Punishment.
"I believe the current situation at the acute mental health service (Wards 34, 35, 36) is untenable."
At the time of inspection the three wards were at 130 percent capacity.
Boshier said the high use of seclusion and restraint, lack of privacy, blanket restrictions, compromised care and limited opportunity for recovery are indicators of a facility in crisis.
The Chief Ombudsman also found there were discrepancies in the collection and reporting of seclusion and restraint data; training on the use of mechanical restraints did not appear to comply with policy and the relevant restraint policies were out of date.
In Puna Maatai Forensic Inpatient Ward, there had been a significant increase in the use of seclusion in recent years, particularly for Māori service users.
Boshier said he was aware $100 million in funding had been announced for a new facility to replace the Henry Rongomau Bennett Centre and was due to open in 2023.
He said the DHB had plans to address overcrowding and reduce the use of seclusion and restraint.
"However, I've had to repeat recommendations made during earlier inspections which is of concern."
Jane Stevens, whose son Nicky took his own life in the Waikato River in 2015 while in the care of Waikato DHB mental health unit, said the ombudsman's report showed just the tip of the iceberg.
She welcomed the report but said it did not go far enough.
"The overcrowding leads to all the kind of issues we are talking about in terms of the poor quality of care. The issues for the staff working there, the safety issues. You know, going through such awful experiences means that many people don't want to engage with mental health services and that creates huge risks for everybody."
She called for an independent inspection of mental health services at the Waikato DHB.
She and three other families who had lost family members while under care at the DHB wrote to Prime Minister Jacinda Ardern and the Minister of Health last week, calling for the review.
They asked for a response by 15 March.
"There's been plenty of reports calling for the need for changes and yet nothing substantial happens," they said.
"It's time for action."
Waikato DHB said it was largely supportive of the Ombudsman's findings. The DHB said at the time of the inspection it had a number of changes under way to address the issues of overcrowding.
It agreed with the report's finding that the design of the centre brought challenges for staff in both its layout and capacity.
It said the limitations of the building itself were visible in the majority of the recommendations from the inspectors from the Ombudsman's office who suggested upgrades to increase access to facilities, fresh air, natural light and outdoor spaces.
The DHB said the problems would be addressed with the recently announced construction of a new facility.
It said the Waikato region had experienced a significant increase in demand for mental health services in recent years and services were increasingly supporting patients who had acute and complex needs.
The DHB said the Henry Rongomau Bennett Centre had during the review period experienced an unprecedented demand which required patients to be accommodated in areas which had to be converted.
It said the mental health service would never turn away a patient who presented with acute need, so needed to find ways to accommodate and care for all those needing an inpatient admission each day.
The DHB said it had opened seven additional bedrooms over the past six months and had contracted a community provider to accommodate an additional 10 bedrooms. This had alleviated some of the pressure, reducing the occupancy levels closer to 100 percent.
Stevens said even though a new mental health unit was to be built, something had to be done immediately.
"I have never supported another big monolith on the hospital grounds and I don't think you can leave this problem until way in the future."
She said it was not all about the building.