report on an unannounced visit to wahi oranga mental ... · family/whanau. 1 acting under...

COTA Report

Report on an unannounced visit to Wahi Oranga Mental Health Inpatient Unit Under the Crimes of Torture Act 1989

19 April 2016

Judge Peter Boshier Chief Ombudsman National Preventive Mechanism

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Office of the Ombudsman | Tari o te Kaitiaki Mana Tangata

Report: COTA Mental Health |

Contents

Executive Summary _____________________________________________________ 5

Background __________________________________________________________________ 5

Summary of findings ___________________________________________________________ 5

Recommendations ____________________________________________________________ 6

Consultation _________________________________________________________________ 6

Facility Facts ___________________________________________________________ 7

Wahi Oranga Mental Health Inpatient Unit _________________________________________ 7

Region ______________________________________________________________________ 7

District Health Board (DHB) _____________________________________________________ 7

Operating capacity ____________________________________________________________ 7

Unit Manager ________________________________________________________________ 7

DAMHs ______________________________________________________________________ 7

Last inspection ________________________________________________________________ 7

The Visit ______________________________________________________________ 8

Visit methodology _____________________________________________________________ 8

Evidence ____________________________________________________________________ 9

Recommendations from previous reports (November 2012) ___________________________ 9

Treatment ___________________________________________________________________ 9

Torture or cruel, inhuman or degrading treatment ___________________________________ 9

Seclusion ____________________________________________________________________ 9

Intensive Psychiatric Care (IPC) __________________________________________________ 12

Environmental restraint _______________________________________________________ 12

Clients’ views on treatment ____________________________________________________ 12

Recommendations – treatment _________________________________________________ 13

Wāhi Oranga Comments _______________________________________________________ 13

Protective measures ____________________________________________________ 13

Complaints process ___________________________________________________________ 13

Records ____________________________________________________________________ 14

Recommendations – protective measures _________________________________________ 14

Wāhi Oranga comments _____________________________________________________ 14

NPM further comments _____________________________________________________ 14

Material conditions _____________________________________________________ 14

Accommodation _____________________________________________________________ 14

Food _______________________________________________________________________ 15

Recommendations – material conditions __________________________________________ 16

Activities and communications ____________________________________________ 16

Outdoor exercise _____________________________________________________________ 16

Leisure activities _____________________________________________________________ 16

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Tari o te Kaitiaki Mana Tangata | Office of the Ombudsman

| Report: COTA Mental Health

Access to visitors/external communication ________________________________________ 17

Recommendations – activities and communications _________________________________ 17

Wāhi Oranga comments _____________________________________________________ 17

NPM further comments _____________________________________________________ 18

Acknowledgement _____________________________________________________ 18

Appendix 1. Informal client – agreement to stay in the IPC _____________________ 19

Appendix 2. Weekly programme of unit activities _____________________________ 20

Appendix 3. IPC Guidelines extract ________________________________________ 21

Appendix 4. Overview of OPCAT – Health and Disability places of detention ________ 22

Tables

Table 1: Seclusion use - July 2015 to March 2016 ___________________________________ 11

Figures

Figure 1: Seclusion room _______________________________________________________ 10

Figure 2: Seclusion area _______________________________________________________ 10

Figure 3: Walk way to IPC from seclusion __________________________________________ 10

Figure 4: Day room/ quiet room in seclusion area ___________________________________ 10

Figure 5: IPC bedroom _________________________________________________________ 12

Figure 6: IPC lounge ___________________________________________________________ 12

Figure 7: Typical bedroom ______________________________________________________ 15

Figure 8: TV lounge ___________________________________________________________ 15

Figure 9: Meal choice _________________________________________________________ 15

Figure 10: Dinning area ________________________________________________________ 15

Figure 11: Courtyard __________________________________________________________ 16

Figure 12: Garden area ________________________________________________________ 16

Figure 13: Sensory room _______________________________________________________ 17

Figure 14: Occupational therapy room ____________________________________________ 17

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Executive Summary

Background

1. In 2007, the Ombudsmen were designated one of the National Preventive Mechanisms (NPMs) under the Crimes of Torture Act (COTA), with responsibility for examining and monitoring the general conditions and treatment of clients in New Zealand secure hospitals.

2. On 19 to 20 April 2016, Inspector Tessa Harbutt and Inspector Thomas Hunecke (to whom I have delegated authority to carry out visits of places of detention under COTA1) visited Wahi Oranga Mental Health Inpatient Unit which is part of Nelson Marlborough District Health Board.

Summary of findings

3. The Inspectors’ findings may be summarised as follows:

There was no evidence that any clients had been subject to anything that could be

construed as torture, or cruel, inhuman or degrading treatment in the six months preceding the visit.

Generally, clients were complimentary about the staff in the Unit and felt there was someone they could turn to if they had any concerns.

Inspectors observed good client/staff relationships with respectful interaction taking place.

The complaints process was widely advertised.

Clients stated that they had their own bedroom which they could lock, if they chose to and access to clean bedding and showers daily.

Clients could easily access fresh air in the external garden/courtyard.

There were no complaints about the food, access to the telephone or access to family or friends.

Information provision on a wide range of topics was easily available to clients and their family/whanau.

1 Acting under delegation of the NPM Chief Ombudsman Judge Peter Boshier and Ombudsman Professor Ron

Paterson.

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4. The issues that need addressing were as follows:

Clients being managed in the seclusion area do not get access to daily fresh air.

New admissions are regularly admitted into a seclusion room before moving to the main unit.

The Unit’s main door was locked, but no communications policy was in place to explain the process to visitors and informal clients wishing to access/exit the Unit.

One informal client was being managed in the Intensive Psychiatric Care (IPC) area.

The weekly activities/programmes on offer to clients were limited.

Recommendations

5. I recommend that:

a. Clients undergoing a period of seclusion should be offered access to daily fresh air.

b. Unless warranted, new admissions should not routinely be admitted into a seclusion room.

c. The Unit should develop a locked door policy detailing the process for entry and exit into the Unit for informal (voluntary) clients (and visitors). This should be displayed in prominent areas, including the Unit entrance.

d. Only clients under the Mental Health (Compulsory Assessment and Treatment (MHA)) Act should be managed in the IPC area.

e. The Unit should consider reviewing the weekly activities on offer to clients. This should be done in consultation with clients.

6. Follow-up visits will be made at future dates as necessary to monitor implementation of the recommendations.

Consultation

7. A draft copy of this report was forwarded to Wahi Oranga Mental Health Inpatient Unit for comment as to fact, finding or omission prior to finalisation and distribution. Their comments can be found in the body of the report following each recommendation.

8. Under sections 27 and 36 of the Crimes of Torture Act, it is the intention of the Chief

Ombudsman to report to Parliament on his analyses of inspections carried out. Of course such reports will be published. It seems fair and proper to advise you that this will occur as of now.

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Facility Facts

Wahi Oranga Mental Health Inpatient Unit

The Unit is an adult mental health inpatient service that works with clients in the acute phase of a mental illness. Clients come from Golden Bay, Marlborough and the Nelson District. Since our last inspection (2011) the Unit is now a locked facility.

Clients are admitted for the purpose of assessment and treatment; the focus is on enabling clients to maximise their independence through partnership, community integration and is recovery based.

Region

Nelson

District Health Board (DHB)

Nelson Marlborough

Operating capacity

26 adult beds (plus 4 intensive psychiatric unit (IPU) beds, and 2 seclusion rooms)

Unit Manager

Nathan Davis

DAMHs

Dr Heather McPherson

Last inspection

Unannounced inspection 2 February 2011

Announced scoping visit June 2008

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The Visit

9. The visit of Wahi Oranga Mental Health Inpatient Unit (the Unit) took place on 19 to 20 April 2016 and was conducted by Inspector Tessa Harbutt and Inspector Thomas Hunecke.

Visit methodology

10. The team leader of the Unit provided the following information during and after the visit:

A list of clients and the legislative reference under which they were being detained (at the time of the visit).

The seclusion and restraint data for the previous nine months and the seclusion and restraint policy.

The number of complaints for the previous twelve months and the complaints policy.

Information for clients on admission.

Visits policy.

Activities programme.

A list of all staff trained in use of restraint and reasons for those not up to date.

11. At the commencement of the visit the Inspectors met with the team leader, before being shown around the Unit. On the day of the visit there were 22 clients in the Unit comprising 10 males and 12 females. The average length of stay is 11 days.

12. There have been eight adolescent admissions in the previous nine months.

13. The following areas were examined on this occasion to determine whether there had been torture, or cruel, inhuman or degrading treatment or punishment, or any other issues impacting adversely on detainees. 2

Treatment

Torture, or cruel, inhuman or degrading treatment

Seclusion

Intensive Psychiatric Care (IPC)

Environmental restraint

Clients’ views

2 Our inspection methodology is informed by the Association for the Prevention of Torture’s Practical Guide to

Monitoring Places of Detention (2004) Geneva, available at www.apt.ch.

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http://www.apt.ch/



Protective measures

Complaints process

Records

Material conditions

Accommodation

Sanitary conditions

Activities and communications

Outdoor exercise

Leisure activities

Access to visitors

Evidence

14. In addition to the documentary evidence provided at the time of the visit, Inspectors spoke to the team leader, staff and clients. Inspectors also reviewed the health records, were provided additional documents upon request by the staff, and observed the facilities and conditions.

Recommendations from previous reports (November 2012)

15. There were no recommendations following our visit in November 2012.

Treatment

Torture or cruel, inhuman or degrading treatment

16. There was no evidence that any clients had been subject to anything that could be construed as torture, or cruel, inhuman or degrading treatment in the six months preceding the visit.

Seclusion

Seclusion facilities & incidents

17. The two seclusion rooms (both with en-suite facilities) were separate from the main unit. Rooms had heating and natural light and a means of raising the alarm. Windows had blinds for privacy. The placement of the bed could be problematic for staff needing to exit the room following a restraint incident. The seclusion area was clean, tidy and well maintained.

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Figure 1: Seclusion room Figure 2: Seclusion area

18. There is a small TV lounge/day room adjacent to the seclusion rooms (a converted seclusion room). Access to the seclusion area is through a long corridor leading from the IPU area, or through the dining area of the main unit - which would be unsafe.

Figure 3: Walk way to IPC from seclusion Figure 4: Day room/ quiet room in seclusion area

19. 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.

20. Due to the location of the seclusion rooms, nursing observations and engagement with clients is limited. Discussions are taking place to allocate a dedicated nurse to the

seclusion area each shift. This will enable more opportunities for engagement with clients and a reduction in seclusion hours. This will also have an impact on general staffing levels.

21. There have been 125 episodes of seclusion involving 79 clients and a total seclusion time of 3,053 hours for the period July 2015 - March 2016 (average 2.2 incidents a week). The

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longest period of seclusion was 204 hours and average time spent in seclusion was 24.4 hours; nearly double that of the previous year – 13.9 hours.

Table 1: Seclusion use - July 2015 to March 2016

July

2015

Aug Sept Oct Nov Dec Jan

2016

Feb Mar Total

Episodes 7 12 17 11 19 24 16 10 6 125

Clients 3 7 11 8 9 14 14 8 5 79

Total Hours 92.2 284 359.1 124.4 407.2 1046 453.4 241.4 44.1 3053

Av time per episode 13.2 18.9 21.1 11.3 21.4 43.6 28.3 24.1 7.4 24.4

22. For the period July 2015 - March 2016 there were 228 admissions into the Unit. Seventy nine clients (34.6 per cent) had been nursed in seclusion at some point during this period.

23. For the same period there were 38 restraint events. Clarification was sort as to why the incidents of restraint were considerably lower given seclusion is considered an intervention of last resort. Feedback received was that some clients walk to seclusion following negotiation and de-escalation by Unit staff; and a number of new admissions tend to be admitted through seclusion, which is not appropriate.

24. Of note, neither the police nor the Unit record restraint incidents if the client is bought in restraints (handcuffs).

Seclusion & restraint policy

25. The mental health service is currently in the process of reviewing and updating their seclusion policy document. The Inspectors were provided with a copy of the old policy

and the new one (still in draft) “restraint minimisation and safe practice policy and procedures.”

26. The service has changed the training provided for managing violence and aggression and are currently updating all staff in the new techniques. This new training is called SPEC (Safe Practice Effective Communication). Not all staff was trained in SPEC at the time of the visit, but future dates for training have been arranged.

27. Efforts are being made to look at seclusion use for this service. The results of this endeavour are still to be realised with current seclusion use remaining high. From

discussions with staff it became apparent that staff have been managing a number of high risk clients with little support from the local police. This appears to be impacting on staff’s confidence and ability to manage the risks safely without resorting to seclusion.

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Intensive Psychiatric Care (IPC)

28. Adjacent to the main unit, the IPC has four beds for clients who are unable to be managed in the main unit, usually because of their heightened anxiety levels and unpredictable behaviour. All rooms have en-suite facilities with heating and natural light. There is a spacious lounge area which leads onto an enclosed courtyard with adequate seating and shade. Graffiti on day room wall detracts from the otherwise clean and presentable space.

Figure 5: IPC bedroom Figure 6: IPC lounge

Environmental restraint

29. Since our last inspection (Nov 2012) the Unit has become a locked facility (environmental restraint). There was no visible signage stating that the main door was locked, or when this decision would be reviewed. The Unit does not have a locked door policy or corresponding locked door register. Informal/voluntary clients have to negotiate with staff all leave requests. This is a significant power imbalance for clients and could be considered coercive practice and not in keeping with recovery based principles.

Clients’ views on treatment

30. The Inspectors spoke with several clients. Generally, they were complimentary about the staff in the Unit and felt there was someone they could turn to if they had any concerns.

31. A lack of activities in the Unit was raised as an issue by some clients and the consumer support advocates.

32. One informal client reported feeling coerced into not leaving the Unit for fear of the Mental Health Act being activated.

33. Clients and advocates reported frustration concerning lack of family involvement in the care planning process.

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34. Clients stated that they had their own bedroom which they could lock, if they chose to and access to clean bedding and showers daily.

35. Clients could easily access fresh air in the external garden/courtyard.

36. There were no complaints about the food, access to the telephone or access to family or friends.

Recommendations – treatment


a. Clients undergoing a period of seclusion should be offered access to daily fresh air.

b. Unless warranted, new admissions should not automatically be admitted to a seclusion room.

c. The Unit develops a locked door policy detailing the process for entry and exit into the Unit for informal (voluntary) service users (and visitors). This should be displayed in prominent areas, including the Unit entrance.

Wāhi Oranga Comments

Point 23 and recommendation b;

This seems to imply a default option for all admissions. This is definitely not the case. By far the

majority of our clients are admitted to the open ward or IPC area. However we have identified

admissions to seclusion (when they do occur) as an area for special attention as this may be an

‘easy fix’ in a first approach to reducing our seclusion hour statistics. New patients are more likely

to be secluded due to (in part at least) unknown risk factors, and with greater assessment and

support we hope to reduce this.

Protective measures

Complaints process

38. The complaints process is readily available with feedback forms and a post box for submitting concerns/complaints or compliments. Contact details for District Inspectors were displayed in the seclusion area and on the white bored in the main unit.

39. In bedrooms, there is a ‘service user information pamphlet’ which details the complaints process as well as patients rights. Also within the pack is a leaflet detailing the DHB’s zero tolerance to offences committed against their staff with all offences reported to the police.

40. The number of complaints in the last twelve months was nine. The Inspector reviewed the complaints and requested the details of four complaints due to the concerns raised.

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41. The process for dealing with complaints is in place and the complaints raised had been appropriately responded to.

Records

42. There were 22 clients in the Unit on the day of the visit and the Inspectors checked all of their files. Thirteen clients were being detained under the Mental Health (Compulsory Assessment and Treatment) Act and nine were informal (voluntary) admissions.

43. All files contained the necessary paperwork to detain [and treat] the clients in the Unit (under the MHA).

44. One informal client had signed a piece of paper stating they wished to be managed in the IPC area (see Appendix 1). This is not appropriate.

Recommendations – protective measures


d. Only clients under the MHA should be managed in the IPC area.

Wāhi Oranga comments

Point 44 and recommendation d;

This omits to mention that the client has signed a consent to being nursed in IPC and that we have

a policy to release the client at any time they request: our clinical director, DAMHS and inpatient

psychiatrist has made this clear.

NPM further comments

46. Appendix 1 is a copy of the signed piece of paper supplied to the Inspectors at the time of the inspection3. It does not specify the client’s right to leave at anytime, the process for doing so and how this information will be captured. The paper is not dated, has no review process or countersigned by anyone in authority.

Material conditions

Accommodation

47. Client bedrooms (none with en-suite facilities) are reasonably spacious, with adequate storage and natural light; all windows have curtains for privacy. There were adequate bathroom facilities for all clients. Bedroom doors can be locked from the inside.

3 Signature was omitted to protect the clients’ privacy.

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48. The nursing stations are spacious and have unobstructed views of the Unit. There are several lounges, communal areas and a small gymnasium for clients.

Figure 7: Typical bedroom Figure 8: TV lounge

49. The facility, both inside and out was clean, tidy and well maintained.

50. The service also has Tipahi Mental Health rehabilitation unit. This supports community clients before they may require an acute admission and offers supportive discharge for clients with higher needs.

Food

51. Meals are prepared in the main hospital and bought to the Unit in a trolley. Clients have a choice of meals from a daily menu. The quantity and quality of the food on the day of the visit was satisfactory. There were no complaints from clients about food.

52. Breakfast is scheduled from 8.00am; lunch is at noon and the evening meal is served from 5.00pm. Refreshments are available throughout the day from the kitchen. Clients can eat their meals at a variety of locations across the Unit, however there is a designated dining area for clients to utilise if they so wish.

53. There were no concerns with regards to the quality or quantity of meals.

Figure 9: Meal choice Figure 10: Dinning area

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Recommendations – material conditions

54. I have no recommendations to make.

Activities and communications

Outdoor exercise

55. All clients in the main unit have ongoing access to a large courtyard and garden area. Clients were observed frequently utilising both areas.

Figure 11: Courtyard Figure 12: Garden area

56. The Inspectors had no concerns about clients’ access to fresh air.

Leisure activities

57. A full-time occupational therapist (OT), and client advocates provide limited activities, both on and off the Unit Monday – Friday for those clients well enough to participate (see Appendix 2). The OT also works with clients to utilise sensory modulation as a means of de-stressing and de-escalating. Clients and advocates reported frustration at a lack of activities within the Unit.

58. The activities room was bright and spacious and contained a kitchen area for cooking groups.

59. From observations and discussions with clients and advocates the Inspectors felt clients have limited access to activities within the Unit.

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Figure 13: Sensory room Figure 14: Occupational therapy room

Access to visitors/external communication

60. Visit times are in keeping with the general side of the hospital but flexibility is advertised and clients can organise visits outside of normal visits times. Visits are usually between 3pm - 8.30pm.

61. The visitors’ room was warm and welcoming.

62. There are two phones which clients can access in the main unit, both offer adequate privacy.

63. Clients in IPC and seclusion have access to a portable phone to make calls.

64. Clients can use the family room for visits and the decor is warm and welcoming.

Recommendations – activities and communications


e. The Unit should consider reviewing the weekly activities on offer to clients. This should be done in consultation with clients.

Wāhi Oranga comments

We regularly review the group programme and adapt as needed to suit the changing client

population here. I feel the report painted a slightly negative light on what we offer here by

focusing on the ‘limited activities’. Although we offer groups Monday to Friday we also have a big

focus on trying to reengage clients in meaningful activity out in the community. Where possible

we aim to support clients to get back into their normal everyday activities and see a lot of value

in working on individual plans/interventions as opposed to focussing on running more groups and

only having clients engaged in activities on the ward. We are also trying to focus more on having

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individual activities available for people to engage in that don’t require staff facilitation or

restrictions around them. A big part of this is sensory modulation and finding out what activities

are helpful for people so that as a staff group we can help to support them in these activities

whilst at Wāhi Oranga and make available what we can. We understand that there is always

more that we could be doing and offering so are reviewing this regularly also. Hope this helps to

clarify things a bit and thanks for taking feedback.

NPM further comments

66. Re-engaging clients in meaningful activities in the community is hugely beneficial to the recovery journey; however, the facilitated structured activities for those clients unable to leave the Unit were limited.

Acknowledgement

67. I appreciate the full co-operation extended by the manager and staff to the Inspectors during their visit to the Unit. I also acknowledge the work involved in collating the information sought by the Inspectors.

Judge Peter Boshier Chief Ombudsman National Preventive Mechanism

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Appendix 1. Informal client – agreement to stay in the IPC

Agreement to Stay in IPC as an Informal Client. I have agreed to stay in the IPC environment in the Mental Health Admissions Unit.

I am aware that I am an informal client and that I am staying in IPC by my own choice as I currently

find this to be a beneficial environment.

Signed

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Appendix 2. Weekly programme of unit activities

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Appendix 3. IPC Guidelines extract Treatment of Informal Patients in IPC:

The use of IPC for informal clients will not be a common occurrence and due care must be taken when considering this as a treatment option.

The use intensive psychiatric care for informal patients must only be considered when:

The client receives a full explanation of IPC and the clinical reasons for using IPC as a care option.

The clients consent is freely given and a written consent form is completed. (document link )

The clients family/whanau are informed.

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Appendix 4. Overview of OPCAT – Health and Disability places of detention

In 2007 the New Zealand Government ratified the United Nations Optional Protocol to the Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment (OPCAT). The objective of OPCAT is to establish a system of regular visits undertaken by an independent national body to places where people are deprived of their liberty, in order to prevent torture and other cruel, inhuman or degrading treatment or punishment.

The Crimes of Torture Act 1989 (COTA) was amended by the Crimes of Torture Amendment Act 2006 to enable New Zealand to meet its international obligations under OPCAT. Section 16 of COTA defines a “place of detention” as:

“…any place in New Zealand where persons are or may be deprived of liberty, including, for example, detention or custody in…

(d) a hospital

(e) a secure facility as defined in section 9(2) of the Intellectual Disability (Compulsory Care and Rehabilitation) Act 2003…”

Pursuant to section 26 of COTA, an Ombudsman holding office under the Ombudsmen Act 1975 was designated a National Preventive Mechanism (NPM) for certain places of detention, including hospitals and the secure facilities identified above.

Under section 27 of COTA, an NPM’s functions, in respect of places of detention, include:

1. to examine the conditions of detention applying to detainees and the treatment of detainees; and

2. to make any recommendations it considers appropriate to the person in charge of a place of detention:

a. for improving the conditions of detention applying to detainees;

b. for improving the treatment of detainees;

c. for preventing torture and other cruel, inhuman or degrading treatment or punishment in places of detention.

To facilitate the exercise of their NPM functions, the Ombudsmen have delegated their powers to inspect places of detention to Inspector’s (COTA). This is to ensure that there is a clear distinction between the Ombudsmen’s preventive monitoring function under OPCAT and the Ombudsmen’s investigation function under the Ombudsmen.

Under COTA, NPMs are entitled to:

1. access all information regarding the number of detainees, the treatment of detainees and the conditions of detention;

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2. unrestricted access to any place of detention for which they are designated, and unrestricted access to any person in that place;

3. interview any person, without witnesses, either personally or through an interpreter; and

4. choose the places they want to visit and the persons they want to interview.

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