Inspectors from the Children’s Commissioner’s office visited the Regional Rangatahi Adolescent Inpatient Service (RRAIS), a 12-bed facility in Porirua, twice in the past year and a half and found a host of alarming issues involving staff, the physical condition of the department and the well-being of the patients.
Their reports, as of yet undisclosed, contain numerous examples of poor design and maintenance – including broken windows, no curtains in the girl’s bedrooms, “tired and depressing” furnishing, numerous ligature points and broken locks – that left the building. unsuitable for very vulnerable patients with conditions such as psychosis.
The inspectors also expressed concern that distressed teens were being held for up to two and a half days in a cold, barren enclosure where some were given cardboard jars nicknamed “cowboy hats” to go to the toilet, and the only outdoor space was a ” small cage covered with wire mesh” visible from a public street.
Safety concerns at the “rundown, dilapidated” facility were exacerbated by a critical shortage of skilled workers to care for the young patients, inspectors said.
“Staff were concerned for mokopuna’s safety on the unit and feared serious injury or death,” they said in one of the reports. “They described the unit as ‘chaotic’ or ‘in crisis’ due to unsafe staffing levels and a chronic shortage of experienced personnel.”
RRAIS, part of the Kenepuru Hospital complex, is one of three specialist inpatient psychiatric units for young people in New Zealand, serving patients from Gisborne to Wellington. It was administered by the Capital & Coast district health council until a major restructuring this month merged all DHBs into a national operational body known as Health New Zealand.
Judge Frances Eivers, the children’s commissioner, told the Herald that the condition of the rangatahi unit was “deeply concerning”.
“My team and I will follow this closely,” she said.
Karla Bergquist, executive director of mental health services in the Capital, Coast and Hutt Valley region at Health New Zealand, said the authority has accepted the recommendations and has taken steps to address them since the inspectors’ last visit in January. .
RRAIS is trying to hire new staff to fill vacancies, Bergquist said, although “recruitment both nationally and locally remains a challenge.”
“We recognize that the facility is outdated and does not provide an optimal therapeutic environment,” Bergquist said. Some maintenance work has been carried out since the last inspection, but these were delayed due to the coronavirus pandemic.
De Bode received the inspection reports as part of an investigation into the state of mental health care. Interviews with dozens of service users, data from multiple government agencies and thousands of pages of documents from government and health authorities have shown how DHBs across the country are struggling to cope with a rising tide of mental distress, exacerbated by the Covid-19 pandemic. .
Exhausted by years of underfunding and poor planning, public mental health providers are now desperately short of psychiatrists, psychologists, nurses and other skilled staff needed to meet rising needs, the study found. As a result, many desperately ill people do not receive effective treatment when they need it and workers work in grueling and unsafe conditions.
The Children’s Commissioner made a surprise visit in March 2021 and inspectors detailed their findings in a report in October. The report has not been published by the children’s watchdog, but the Herald obtained a copy under the Official Information Act from Capital & Coast DHB.
“We saw mokopuna and staff struggle with the cramped, run-down and dilapidated conditions in Rangatahi,” the inspectors said. “Whānau were ‘appalled’ at the physical condition of the facility when they arrived.”
Staff pointed out issues they claimed had been unsolved for years: broken windows, crumbling window frames, windows covered in plywood, missing curtains in girls’ bedrooms, a dysfunctional duress alarm, offensive graffiti and dilapidated furniture.
Indoor spaces were cramped, while use of the limited outdoor space was limited because there weren’t enough staff to supervise, the inspectors noted. The food was monotonous and unsuitable. If patients wanted to call their relatives, they had to use a telephone outside the nursing station that offered no privacy.
Inspectors expressed concern that some patients were being held in a “bare” confinement area.
It has long been a practice in psychiatric wards to treat agitated patients by physically holding them or confining them in a confined space until they settle down, but in recent years there has been a push to eliminate these methods because they are extremely can be traumatic and there are more effective ways to calm those in need.
At RRAIS over the past year, a dozen patients had been held for between 10 minutes and 68 hours in a locked room that was in poor condition, the inspectors found.
The temperature in the seclusion room was “considerably cold” despite the fact that some patients were kept there only in a hospital gown. There was no outdoor space for secluded patients, except for a “small cage covered with mesh” with no seating that was “clearly visible from a public road”.
“Given the age and fragility of the mokopuna in Rangatahi and the conditions in the seclusion unit, we are deeply concerned about the use of seclusion,” the inspectors said.
Due to chronic understaffing, employees regularly worked double shifts. The staff complained of high turnover, burnout and frustration at “not being able to work on their job descriptions because they were too busy ‘trying to keep these kids alive'”. Patients told inspectors that they were not getting the effective treatment they needed to get better.
After that visit, the inspectors demanded a range of improvements, including urgent renovation, abolishing the use of seclusion and coercion, and recruiting new staff to ensure there are a sufficient number of trained professionals in each service.
In January, during a Covid lockdown, the Children’s Commissioner went back for another inspection.
This time, inspectors found that some progress had been made: staff culture had improved significantly, in part due to a change of leadership. Patients told inspectors that staff were caring and supportive. And there appeared to be better planning and communication.
However, the inspectors said the unit still did not provide a safe and therapeutic environment for vulnerable young people. While cosmetic improvements had been made since the previous assessment, including new carpets, repaired windows and renovation of a courtyard, inspectors said they “continue to be concerned that the building is not safe or fit for purpose”.
The personnel situation remained “unsafe and untenable”, they said.
“Staff regularly work overtime and described feeling burned out and fatigued,” the January report said. “Many described the current situation as unsafe and felt that the unit would not be able to provide safe, quality care for mokopuna if they were at full capacity.”
Due to chronic understaffing, the use of seclusion and restraint had increased since their last visit, despite their recommendations, the inspectors said. There were 14 isolation “events” in the six months before their last inspection, a “significant increase,” the inspectors said. They lasted up to 54 hours and the youngest incarcerated person was 12.
Conditions in the secluded area were still cold and humiliating and required an “urgent upgrade,” the inspectors said.
Their report also noted that some solitary patients were forced to use cardboard jars (“sometimes referred to as ‘cowboy hats'”), despite there being a bathroom in the seclusion room. They found no clear reason or justification for this, but “it turned out to be routine”.
“This practice endangers the privacy and dignity of mokopuna,” the inspectors said.
In a statement, Health New Zealand’s Bergquist said: “RRAIS is working hard to strike a balance between supporting and treating clients with complex conditions, while also ensuring the safety and protection of other vulnerable clients and staff.”
Isolation is only used as a “last resort, when rangatahi poses a risk to themselves or others, and when other methods of de-escalation have proved unsuccessful”. The increase was due to “three clients with very complex mental health needs”.
Bergquist said the use of cardboard jars is not standard practice and that, in most cases, secluded patients are allowed to use a communal bathroom. However, the bathroom could pose a safety risk because “it can be locked from the inside and has no viewing window, meaning that the staff cannot keep in contact with rangatahi who may be very upset. In this case, rangatahi will be provided with a disposable item of composite material container.
“While we recognize that this process is far from ideal, it remains the safest option,” Bergquist said. The secluded space is scheduled for renovation, including refurbishing the bathroom to protect patients’ privacy and dignity.