An investigation revealed serious issues in the care of a person put in a secure facility because they were unfit to stand trial. The Health and Disability Commissioner found that the person was injured when staff tried to restrain them and was then put in isolation incorrectly. Health NZ failed to provide proper care, which led to the need for surgery after the injury.
The individual, diagnosed with Fetal Alcohol Spectrum Disorder (FASD) and a mild intellectual disability, was sent to the facility in 2019 despite having no prior mental health issues. Due to a lack of appropriate beds, they were placed in a medium secure unit.
Deputy commissioner Dr. Vanessa Caldwell expressed concern about the inadequate training of staff and the lack of suitable facilities for people with complex needs. She expects coordination among Health NZ, the Ministry of Health, and Whaikaha to improve resources for vulnerable individuals.
The individual had faced many challenges, including substance abuse and early trauma. Their care plan emphasized extra support during stressful times to prevent self-harm. When stressed, the person preferred to have space and time alone.
In 2021, after two years in care, a lawyer raised concerns about an incident involving the person being restrained by staff, which led to an injury. During the struggle, the person fell to the ground, resulting in an injury that required surgery. The report noted that staff did not use proper de-escalation techniques and that isolation was wrongly initiated without appropriate leadership.
Caldwell criticized Health NZ for not ensuring a reasonable standard of care, which led to the individual’s injury. She highlighted that staff lacked training to understand the needs of vulnerable clients and stressed the importance of better care facilities.
While Caldwell acknowledged Health NZ’s response to the investigation, she was worried that necessary improvements were not made quickly. Health NZ reported that it accepted the findings and was working on major service improvements.
