A Wakari Hospital patient with intellectual disabilities was almost constantly locked in their bedroom for at least 18 months in conditions the Chief Ombudsman says amounted to prolonged solitary confinement.

Inspectors for the Ombudsman visited the inpatient unit for adults with intellectual disabilities in Dunedin in March.

Last month, Chief Ombudsman John Allen shared the findings, saying inspectors observed some of the worst practices they had witnessed and some treatment amounted to torture.

Health New Zealand confirmed plans to close the ward on the same day, while the Ministry of Health said it would launch an independent investigation that would consider if allegations of human rights abuses should be referred to the police.

John Allen released a longer summary of the concerns and urgent recommendations on Thursday, detailing observations under the heading "punitive, coercive and unlawful treatment".

Inspectors detailed a model of care that appeared to prioritise containing and restricting patients to minimise the immediate risk of physical harm, with little attention given to providing meaningful rehabilitation or person-centred care, the report said.

The ward has faced significant criticism before, with a previous ombudsman calling it "a disgrace".

But the March inspection was triggered by an innocuous visit to check on a refurbishment Health New Zealand said would be underway from mid-2025, which would require patients to be relocated.

During an unannounced visit in October 2025, Ombudsman staff members discovered the refurbishment remained largely in the planning phase and patients had not been moved out.

They became "very concerned" about patients seen living in restrictive environments, flagging this with ward management and government agencies before sending an information request to Health New Zealand.

In December 2025, Health New Zealand confirmed a high level of restrictions remained at Ward 10A.

It prompted that four-day announced visit in March.

"We became very concerned about the conditions and treatment experienced by tāngata whaikaha (whaikaha means 'to have strength, to have ability, otherly abled, enabled')," the report said.

"We were concerned that the practices of the ward were extreme, fostered institutionalisation, risked traumatising tāngata whaikaha and may have constituted abuse."

Inspectors observed that one patient was locked in their bedroom "almost unceasingly" with extremely limited contact.

"We were very concerned that the physical arrangements were increasing the institutionalisation of this tāngata whaikaha, which had persisted for at least 18 months," the report said.

"We considered these arrangements may amount to prolonged solitary confinement."

The attempts to expose the patient to the ward also appeared to be very limited.

"At the time of the inspection, their bedroom door was being unlocked and left open for 90 seconds each day (rather than 30 seconds previously)," the report said.

The Ombudsman said it expected coercion was not used to modify behaviour and tāngata whaikaha had choice where possible.

Instead, the report outlined a pattern of staff incentivising good behaviour so patients could have their basics needs met including losing access to the toilet while in seclusion, being told they would only be able to see a dentist if their behaviour stabilised, or not being allowed to buy things with their own money unless they complied with staff directions.

"We were highly concerned about the potential use of punitive, coercive and unlawful practice on the ward."

Inspectors found patients might not have consented to some of the medication and sedatives they were given, including intramuscular injections.

This is not legal except in limited circumstances.

A bariatric EVAC mat was used to restrain and move patients, resulting in friction burns for some patients, despite the Ombudsman saying the United Nations' Special Rapporteur on Torture had raised concerns about the use of similar restraints and how they should only be used for legitimate medical reasons.

"In our view, moving a tangata whaikaha to a seclusion room is not a 'legitimate medical reason' envisaged by the Special Rapporteur," the report said.

Helensburgh Cottage, which was meant to help people to transition to care providers in the community, had remained empty since the pandemic despite the Ombudsman noting it appeared to be a better environment to provide care.

Staff told inspectors that it was not being used due to staffing pressures.

While detailing facts about Ward 10A, the Ombudsman noted that previous inspection reports found the physical environment was not fit for purpose - a description the former District Health Board also used.

The Ombudsman's concerns were detailed to senior staff at Health New Zealand and the Ministry of Health after the visit, before urgent recommendations were made.

Allen did note that the relevant agencies had taken swift action in response to the concerns and recommendations.

The Ombudsman's recommendations included:

• Health New Zealand urgently improving the "conditions of detention" by ending all prolonged isolation and improving physical living arrangements, activity and care.
• Ending the use of bariatric EVAC mat to restrain and move tāngata whaikaha.
• Urgently take measures to ensure the individual safety and rehabilitation of all tāngata whaikaha on Ward 10A.
• The Ministry of Health making sure an independent investigation was undertaken.
• Immediately reviewing the medications prescribed to tāngata whaikaha on Ward 10A, to ensure that all medication is lawfully prescribed and administered.
• Immediately implementing a model of care in Ward 10A that focusses on tāngata whaikaha well-being and rehabilitation.

Health New Zealand previously said it was taking the allegations made by the Chief Ombudsman and others very seriously.

"We take patient safety and care very seriously and want to acknowledge the patients, their families, and our staff, all of whom we are supporting during this period of change," a spokesperson said.

"Our focus remains on ensuring the safety, dignity, and rights of the current patients, while strengthening oversight and reviewing practices."

Health New Zealand planned to undertake a wider review of forensic intellectual disability services nationally, and said it had already enhanced clinical oversight, reviewed patient care and rehabilitation plans, strengthened approaches to reducing seclusion, and strengthened governance arrangements.

The independent inquiry triggered by the Ministry of Health will report its findings and recommendations to the director-general of health within six months of starting.