*Content warning: This story discusses themes of suicide*
Mental health units are a ‘black box’, with the wider public oblivious to what goes on inside. Oliver Lewis reports in the first in a series on inpatient units examining how our run-down facilities are affecting service users.
On her first day in an Auckland mental health inpatient unit, Emma* noticed the graffiti. The then-25-year-old, who was suicidal and experiencing worsening depression, was struck by the amount on the walls and how — despite some of it being sketched in pencil — nobody had bothered to clean it off. One piece in particular stood out: “This is a fucking prison. Get me out of here, I want to die,” someone had written.
“I was pretty shocked,” she said. It was her first time in an inpatient unit, and the environment felt worn down and shabby.
“It made me feel forgotten.”
About 9500 people received mental health inpatient care in 2020, according to figures provided by the Ministry of Health. Emma was one of them. There would not have been writing on the walls if she had been treated for a physical health condition, the 26-year-old said, nor would she have been on high doses of medication for months without proper follow-up care.
READ MORE IN THIS SERIES
* Part two: Overcrowded mental heath units breach torture convention
* Part three: Mental health units should provide more than ‘meds and beds’
* Part four: NZ’s first ‘new wave’ mental health unit
“It was the irony of it,” Emma said. “You’re supposed to be in a place that’s therapeutic and helping you get better, but the environment is so awful.”
In the past five years, people in acute distress have been cared for in units with leaking, mould, damp walls, fungal growth, insect infestation and pest and rodent issues, according to official documents uncovered by Newsroom.
People in crisis have been treated in places with design features common to prisons; in buildings with cleanliness, ventilation and maintenance issues described as run-down, gloomy, tired, shabby and unsafe. There are well-designed, therapeutic facilities, like the new $64 million Tiaho Mai unit at Middlemore Hospital, others are fine, but too many units are sparse, stark, clinical spaces which are no longer fit for purpose. That needs to change, advocates say, and there needs to be more investment in therapeutic facilities to cater for the most unwell people.
One woman, Jude*, who has been admitted to inpatient units in Christchurch, Wellington and Auckland over the past three decades, was outraged at the lack of intervention to fix some of the worst units. Many people were admitted under the Mental Health Act, she said, so they had no choice but to spend time in these places.
“How and why is it allowed to get to that state? Why is that okay?”
Over the past several months, Newsroom has investigated the condition of mental health and intellectual disability inpatient units to understand how we, as a society, are caring for some of our most vulnerable. We have obtained dozens of documents using the Official Information Act (OIA), including building reports and occupancy data from all 20 District Health Boards (DHB), analysed all relevant Ombudsman reports published since 2018, spoken to people with inpatient experience and talked with experts and staff.
“I went home and cried several times during the course of this research. I was just upset and disgusted at our society that this is how we treat people.”
Dr Gabrielle Jenkin has spent the past four years researching the acute inpatient experience in New Zealand, a groundbreaking project which included interviews with 43 service users, 11 family members and 42 staff across four units. The University of Otago, Wellington academic, who received a prestigious Marsden Fast-Start Grant to fund her work, was warned before she started that she would find conditions in some units shocking. They were, she said.
“I went home and cried several times during the course of this research.
“I was just upset and disgusted at our society that this is how we treat people.”
While some units are run-down and inadequate, almost everyone Newsroom spoke to who had spent time in them said they found aspects of their stay beneficial. There is a sense of relief that comes from being placed in a secure facility, one woman said. Others praised the staff, or said they had benefitted from changes to their medication. For some, it was a matter of life and death.
“It definitely kept me well,” one woman said. “It kept me alive.”
The Government is making some progress. Between 2015 and 2020, $472 million was set aside to refurbish or replace outdated facilities. The Ministry of Health has created a mental health work programme within its health infrastructure unit, and last month officials released new design guidelines for mental health units. The ministry is also working on a national investment roadmap for acute mental health and addiction units, which will include a picture of the current state of facilities.
Meanwhile, people are still receiving care in units Chief Ombudsman Peter Boshier has said need to be upgraded urgently, including those derided as “hopelessly inadequate” by staff. In old design guidance from 2002, the ministry said: “Facility design may act as a tool or impediment to recovery.”
At the moment, too many units are impediments.
‘I felt like I didn’t matter’
For Jayne*, the environment in Te Awakura, a Christchurch acute inpatient unit, felt more like a holding cell than a place of healing. Describing her 2019 stay, she said the ward at Hillmorton Hospital was dark, run-down and in a state of disrepair. Furniture was broken, her room was cold — staff could only offer extra blankets because the heater didn’t work — and, outside, there was a high wire fence facing the motorway, meaning passersby could look in.
“The physical environment played a huge part in how I saw myself,” Jayne said. “I felt like I was being treated like a prisoner. I felt like I didn’t matter.”
The experience negatively impacted her recovery, she said. “I worry that if I get admitted to hospital again then I’ll lose a part of myself to all the resounding feelings of hopelessness that being on the ward gave to me.”
Consultants who assessed facilities at Hillmorton in 2019 said the units, generally single-storey, brick buildings from the 1960s, 70s and 80s, were “showing their age”. Government inspectors who visited that year used the same description for each of the three facilities they looked at, including part of Te Awakura: “the environment is poorly maintained and is run-down”. They didn’t mention vermin, though.
A rodent infestation ahead of a 2018 Ombudsman report meant that inspectors who visited a secure psychiatric intellectual disability unit at the hospital found the courtyard, described as stark and poorly maintained, had been locked. In a response to Newsroom, the Canterbury District Health Board (CDHB) confirmed there had been five pest or rodent issues at the unit and another locked intellectual disability facility at Hillmorton in the past year.
The design of the nurse stations sent a message: “This is not a safe place to be, but the staff are safe. Too bad if you’re out there.”
CDHB specialist mental health services acting general manager Vicki Dent said the health board was waiting on the outcome of a business case submitted last year to the Capital Investment Committee asking for endorsement of a masterplan to start redeveloping facilities at Hillmorton.
Rats and mice aside, though, the issues go far deeper than Christchurch.
In 2019, Ministry of Health officials carried out a nationwide assessment of health infrastructure as part of the National Asset Management Programme (NAMP), a project trumpeted as the first comprehensive look at the state of our hospital buildings. A report, released last June, included assessments of 24 mental health inpatient units. Four were ranked very poor, 11 were poor, six were average and three, including Tiaho Mai, were considered good against the relevant design criteria. A very poor ranking indicated immediate repair or renewal was required. Poor was the same, just with less urgency.
Jenkin, the academic, visited about 10 inpatient units for her research, but focused on a representative sample of four. She praised aspects of Tiaho Mai, but said most inpatient units she saw had major issues and design flaws.
“One was particularly bad, and the rest were just varying gradations of bad.”
Some units smelled like urine, she said. They were noisy and furnished with cheap, ugly and damaged furniture. Describing one tatty couch with peeling vinyl and broken springs, Jenkin remarked: “You wouldn’t even have it in your flat.” Some staff seemed to blame service users for the poor state of the environment, Jenkin said, while others talked about a lack of resources and staff shortages. Whatever the cause, many units were run-down and sparse. “Some felt really dilapidated,” Jenkin said. “It just looked unkempt.”
The courtyards in two units she focused on were stark, “disgusting” and dirty with cigarette butts. Visiting rooms — called whānau rooms — were often undersized, including one which was difficult to photograph because it was so cramped. Occupational therapy and sensory rooms, filled with objects to stimulate the senses of service users, were beneficial, but again they were often small or inaccessible.
Jenkin’s research focus was influenced by Maggie’s centres in the United Kingdom, drop-in charitable spaces housed in purpose-built facilities designed to be warm, calm and welcoming.
“Why can’t we have that for mental health?” Jenkin said. “Because that’s actually what we need.”
Simple things to give service users more autonomy would help, she said, like giving people control of heating and lighting in their rooms and giving them lockers to safely secure their belongings. In general, inpatient units needed to have more space, light and access to nature.
Instead, the 2020 NAMP report found the design of about 70 per cent of the 24 units assessed did not provide proper privacy, safety and therapeutic space to support different patient groups. Interior maintenance at 70 percent of the units was poor, including shabby paintwork, holes in the walls, leaks in ceilings and rippling and worn carpets.
A number of service users told Jenkin they felt like they were in a prison. People were bored because there was a lack of things to do, she said. However, the comment also reflected the physical environment.
The NAMP report backed this up. Over 50 percent of the assessed units had design features common to those first developed for prisons, it noted, including the central, glass-enclosed staff base common to many units. Newsroom spoke to service users who said it made them feel like they were in a fish bowl — like they were constantly being watched. It was frustrating, too, they said, trying to get the attention of the nurses working inside. Often they had to wait a long time for basic things like medication, a phone charger or toiletries.
“You feel like the worst of the worst and so low because you’re in a place that you just do not want to be in,” one woman, Janet*, said. “And then you feel even worse having to wait around.”
The design of the nurse stations sent a message, Jenkin said: “This is not a safe place to be, but the staff are safe. Too bad if you’re out there.”
The NAMP report was publicly released, but unit inspection notes were not. The write-ups, freshly released to Newsroom under the OIA, provide graphic descriptions of some of the worst units in the country. They also praise some units for being well-maintained despite their age.
At Whare Whakaue, in Rotorua, inspectors found an insect infestation spurred by fungal growth under the kitchen. The ward also featured leaking in patient bedrooms and the nursing office, extensive damp on the walls in the dining area and patch repairs to floors to fix rotting and sagging. The 14-bed inpatient unit was built in the 1970s. There was no ability to separate patient groups, inspectors noted, no deescalation area, poor natural light and a flawed floor plan which compromised safe care.
An Ombudsman report from 2019 was equally damning. Boshier, the Chief Ombudsman, recommended the building be upgraded urgently. Staff called a small outside area off the intensive care space “the cage” and tried not to use it because it was “terrible” and “embarrassing”. There were problems with heating and ventilation, staff said, and the unit was “mouldy and leaky”. There was evidence of ant infestation and “the unit had a strong smell of urine in most areas”. The admissions area was an “unwelcoming” space with limited natural light. Inspectors considered it “grim and potentially intimidating”.
“You feel like the worst of the worst and so low because you’re in a place that you just do not want to be in.”
Newsroom asked the Lakes DHB if the unit was still mouldy, leaking and had current issues with fungal growth and insect infestation, and whether this was acceptable. “No. No it would not be acceptable,” a spokeswoman said, adding “the cage” was no longer in use. Provisional designs for a new facility were about to be submitted to the board. The Government had allocated $25m for a new build, which would open in either 2022 or 2023.
Ward 21 at Palmerston North Hospital, another mental health inpatient unit, was described by officials as dark and run-down, with sharp edges and blind spots. “Staff consider the unit a non-therapeutic, dangerous and unsafe environment,” they noted. Issues with Ward 21 have been flagged since at least 2014, when two service users died by suspected suicide. A damning review found the unit design was not conducive to providing safe and effective mental health care. MidCentral DHB mental health and addictions director Vanessa Caldwell said architects started design work for a $35m replacement unit in February.
Hauora Tairāwhiti also has funding for a new inpatient unit. Officials who assessed its current facility, Te Whare Awhiora, said areas weren’t cleaned, maintenance was poor and the overall condition was shabby. “There is vermin and mouse traps are used. The building leaks,” inspectors said. The Gisborne Hospital building, built in the 1980s, had numerous blind spots, the layout was poor and demand hugely exceeded capacity, meaning seclusion rooms — stark, austere spaces often with only a mattress on the floor meant for locking up people deemed to be a risk to themselves or others — were often used as bedrooms.
A 2019 Ombudsman report said the seclusion area was “dirty and oppressive” and there “appeared to be dried faeces on the floor” of one of the rooms. The poor environment meant the use of seclusion rooms as extra bedrooms was likely to have a detrimental impact on the mental wellbeing of service users, Boshier said. He was also concerned young people aged under 18 were being housed in the low stimulus and seclusion area.
A Hauora Tairāwhiti spokeswoman said youth may still be placed on the unit, but not in seclusion. The DHB had addressed all maintenance issues, she said, and tenders had been sought to fix leaking in the roof. “Cleanliness standards are met and we have an active eradication approach to vermin.”
Construction on the new unit was expected to start in 2022 with an estimated build time of 15 months.
While some of the worst units are being replaced, service users and others have questioned why they were ever allowed to get so bad. DHBs, which compete against each other for new build money, have to balance numerous priorities within limited budgets. But by not providing fit-for-purpose mental health facilities, DHBs are undermining care for the vulnerable people they are meant to be helping.
Emma, who spent time in Auckland inpatient unit Te Whetu Tawera last year, said its shabby condition made her feel forgotten. “It made me feel like people don’t really care and the mental health system is really fucked and really underfunded,” she said. Tracy Silva Garay, the mental health and addictions co-director at Auckland DHB, acknowledged some units were tired. It was important to balance the need to provide a warm and inviting place, she said, with the requirement to spend public money carefully. The DHB was in the process of refreshing some of its facilities, she said, including a process to repaint every bedroom and bathroom in Te Whetu Tawera. It also had a new deep clean schedule in place in the unit and was working on a plan to replace worn carpets, among other initiatives.
Replacing units with approved new build plans will take years. The NAMP assessments and Ombudsman reports make it abundantly clear there are many others that also need attention. Some of these are “run-down”, “poorly maintained”, “tired” and “detrimental” to wellbeing. Poorly designed and cramped facilities contribute to violence, higher rates of seclusion and an overall worse experience for the people receiving care.
The dated inpatient facilities at Wakari Hospital, in Dunedin, are among those with no approved replacement plans.
In Ombudsman reports from 2019, Boshier recommended both wards 9A, a secure forensic unit, and 9B at the hospital be upgraded urgently. Service users and staff in 9A had both raised concerns about the heat and lack of adequate ventilation, while inspectors noted the unit was drab and gloomy. Boshier was concerned the unit environment was having a “detrimental effect on patient wellbeing”. He was similarly critical about 9B, a locked acute inpatient unit which one staff member called “hopelessly inadequate”. During her research, Jenkin found many inpatient units had problems with their heating and cooling systems. When inspectors asked to check the temperature in 9B they were told it was 28.1C, an “unacceptable” temperature for a hospital.
One woman with inpatient experience at Wakari, Vicki Wise, said she liked 9B. It was “cosy”, she said. The worst unit she had stayed in was Ward 11, a rehabilitation unit on the third floor of Helensburgh House, a former nurses’ residence built in the 1950s. The NAMP assessment notes describe it as “run-down”, with irregular wall, floor and ceiling coverings. There was a lack of clinical support spaces and a lack of privacy for service users.
“You can’t curl up in your bed and feel comfortable and safe and warm and feel like you’re being cared for in a place like that.”
The unit smelled of urine, Wise said. It was dark, and one of the small lounge areas had been commandeered as a storage space for “junk”. Like erasing pencil graffiti, it would have taken five minutes to move. “But no one had bothered,” Wise said. “No one had bothered to do anything with that ward.”
“It’s a depressing place.”
In a statement, Southern DHB chief executive Chris Fleming said the health board “was very aware of the shortcomings of its facilities”, particularly at Wakari. It created challenges for staff and service users, he acknowledged, adding the DHB had looked at what would be required to bring the facilities up to standard while a longer-term plan was being developed. Mental health was not included in the Dunedin Hospital redevelopment project, but Fleming said the DHB was looking at how more suitable facilities might fit into wider site planning. Ventilation systems in wards 9A and 9B had recently been replaced, he said.
Newsroom asked the Ministry of Health if it was acceptable to have inpatient units with issues including leaking, poor ventilation, pest and insect issues and mould, and to have people cared for in spaces described as oppressive, gloomy and run-down. In a statement, ministry infrastructure deputy director-general Karen Mitchell said the health infrastructure unit within the ministry was working with DHBs to ensure investment addressed issues raised in the NAMP report. There were a range of possible responses, including replacing buildings, refurbishment and improved maintenance. The ministry was progressing the Government’s programme to rebuild and strengthen health infrastructure, Mitchell said, with mental health facilities being a key priority.
“We want all health facilities to be high quality and therapeutic.”
At the moment, it’s clear that many aren’t.
‘Like something out of the future’
Every year, the Health and Disability Commissioner gets about 300 complaints relating to mental health and addiction services. Of these, about 90 relate to inpatient units. Deputy Health and Disability Commissioner Kevin Allan said few of these relate to buildings. Most are to do with things like admissions under the Mental Health Act, treatment issues or how information is communicated to whānau. Allan believed the culture in inpatient units was more important than physical infrastructure, but agreed that having good facilities was important.
As the former Mental Health Commissioner, Allan visited numerous inpatient units around New Zealand. Many were old, tired and in need of a fix-up. “I am concerned about some of the facilities around the country,” he said. There needed to be a “systematic way of improving facilities and continually updating, redesigning and replacing facilities that are beyond their use-by date”.
While it was important to invest in the units themselves, Allan said there needed to be better facilities and support in the community. It was crucial to support people before they became so unwell they needed inpatient care, and to provide better step-down care after they left.
The CDHB, which runs inpatient services at Hillmorton, also funds an acute alternative service called Te Ao Marama. The seven-bed facility, which is run out of a house in the community by Pathways, an NGO, opened in 2019. The service is peer-led, meaning staff have their own lived experience.
For Janet*, the difference between Hillmorton and Te Ao Marama was huge. Going inside the converted villa was like “walking into a magazine”, she said. It was warm, well-designed and beautiful, with artworks on the walls and colour everywhere. A chef cooked dinner using vegetables sourced from organic gardens at the house. The lounge had a huge TV and there was a well-stocked sensory room and comfortable beds.
By contrast, the environment in the acute inpatient unit at Hillmorton during her 2018 stay was cold, clinical and stark, Janet said.
“You can’t curl up in your bed and feel comfortable and safe and warm and feel like you’re being cared for in a place like that.”
When Janet was admitted to Te Ao Marama a year later, in 2019, just being there felt like a relief. It was like “I feel good about being here and I know I’m going to get better”, she said. Some people would be too unwell to access the service, but for people like her, Janet said it was a much better model than the inpatient environment.
“It’s like something out of the future. This is what they should be doing more of now.”
*Emma, Jude, Jayne and Janet are not their real names. Newsroom has agreed to use pseudonyms to protect their identity. If you want to share your inpatient experience email firstname.lastname@example.org
This project was funded by Nōku te Ao Like Minds, with support from the Mental Health Foundation
All contributing artists are part of the Ōtautahi Creative Spaces creativity community, in Christchurch
Where to get help:
1737, Need to talk? Free call or text 1737 any time for support from a trained counsellor
Lifeline – 0800 543 354 or (09) 5222 999 within Auckland
Samaritans – 0800 726 666
Suicide Crisis Helpline – 0508 828 865 (0508 TAUTOKO)
thelowdown.co.nz – or email email@example.com or free text 5626
Anxiety New Zealand – 0800 ANXIETY (0800 269 4389)
Supporting Families in Mental Illness – 0800 732 825