*Content warning: This story discusses themes of suicide*

Mattresses on the floor, makeshift bedrooms and “sleepovers”. In the second piece in a series on mental health inpatient units, Oliver Lewis reports on how overcrowding is breaching a United Nations convention against torture and degrading treatment.

The Henry Rongomau Bennett Centre was crowded. When Ombudsman inspectors visited the Waikato mental health facility in 2019, it was running at well over 100 percent of its funded bed numbers. Seclusion rooms, day rooms and whānau rooms had all been taken over as makeshift bedrooms. One woman was asleep on a mattress in a consulting room with no natural light. The overhead lights were on and the door was unlocked. In his 2020 report, Chief Ombudsman Peter Boshier worried she was at risk of harm. The woman, who was not being monitored, was in a room beside the male corridor.

Boshier was scathing. The Waikato District Health Board (WDHB) has funding approved for a replacement centre, but the current one was a facility in crisis, he said. The over-occupancy issue was unsustainable, unsafe and degrading to service users.

Using the Official Information Act (OIA), Newsroom got occupancy statistics from every DHB in the country. The data doesn’t lie: this is a nationwide problem. The responses also revealed numerous breaches of a United Nations convention against torture and degrading treatment, as defined by Boshier, including DHBs using seclusion rooms — austere spaces meant for locking up people deemed a risk to themselves or others — as overflow bedrooms. 

In the year to November 2020, 13 of the 18 DHBs (the three Wellington region DHBs responded as a collective) had at least one month where the average monthly occupancy rate in their acute mental health units was at 100 percent or more of their funded bed numbers. Many were full for months in a row. Internationally, the ideal average occupancy for inpatient units is meant to be 85 percent, according to the Ministry of Health.

On the left, an interview room being used as a bedroom; on the right, a shared bedroom with partial wall for separation – both at Henry Rongomau Bennett Centre in the Waikato. Photos: Taken from the Ombudman’s report on an inspection of Wards 34, 35 and 36, Waikato Hospital, under the Crimes of Torture Act 1989.

The units were full, but they were also too small. Of the 24 mental health inpatient facilities assessed as part of a national infrastructure stocktake in 2019, 75 percent were smaller than the Australasian guidelines.

“Nobody functions well in a crowded space,” said Helen Garrick, the chair of the mental health nurses section of the New Zealand Nurses’ Organisation (NZNO), a union.

What people want from an inpatient unit is a quiet, therapeutic environment they can go to in times of crisis to feel safe. The reality is often far different. Newsroom has spoken to people who said they were discharged too early or shuffled between wards to free up beds, couldn’t access intensive care because the space was full, and a researcher whose interviews were disrupted because it was so noisy.

“Our members do talk about overcrowding,” Garrick said, “and the dilemmas that they are continually placed in when they are required to admit people into units that are already full.”

Garrick has been in her role for about five years. During that time, high occupancy has been an ongoing issue. It has not been getting any better, she said.

For nurses, it is a juggling act with a high degree of risk. Do you turn away a person feeling suicidal or do you do your best to find a space? A number of DHBs, including Waikato, say they won’t turn people in acute distress away. 

“There have been other times in my life I’ve presented to the emergency department and said ‘I’m really suicidal’, and they’ve given me valium and sent me home because these wards are at capacity.”

In Wellington, the adult acute inpatient unit Te Whare O Matairangi had more people than its funded number of beds for 234 days of the year to November 2020. Its average occupancy for the period was 103.8 per cent. In the Bay of Plenty, the inpatient unit at Tauranga Hospital, Te Whare Maiangiangi, was over its funded capacity for 208 days of the year. Counting people on leave (service users deemed well enough for periods off the unit) but still under the care of the service, the adult inpatient service at Waikato DHB exceeded its funded occupancy 238 days of the year. Without leave, it was 149 days. Inpatient units are funded for a set number of beds, but often have extra. When those get used up, the mattresses get doled out, the couch beds folded out and inappropriate spaces like seclusion rooms become makeshift bedrooms.

Overcrowding invariably leads to problems. In his report on the Henry Rongomau Bennett Centre, Boshier said staff reported not being able to escort people into the courtyards because they were too busy. As a result, people were deprived of fresh air. Garrick, the NZNO mental health sector chair, said it contributed to violence on the wards and meant nurses couldn’t provide the level of care they wanted to.

“If you’ve got too many people in a small space, then you’re going to get tempers fraying and people are going to get irritated with each other.”

‘Get Me Outta Here’, by Catherine Brougham. Photo: Julie Chandelier

Ombudsman reports on some mental health units talked about staff working double shifts to cover gaps and perceptions that staffing levels weren’t high enough to deal with demand. That has an effect.

“We do hear about high turnover,” Garrick said. “We do hear about low morale.”

Following the release of the report on the Henry Bennett Centre, WDHB released a statement saying the inspection took place at a time of unprecedented demand and it had a number of strategies underway to address occupancy issues. In response to Newsroom, a spokesman said the DHB had put in place initiatives to increase capacity, including adding seven bedrooms to the centre and contracting out a 10-bed acute alternative in the community. It had managed to alleviate some pressure, the spokesman said.

* Part one: ‘Dilapidated’ mental health units undermining care
Part three: Mental health units should provide more than ‘meds and beds’
Part four: NZ’s first ‘new wave’ mental health unit

Newsroom has spoken to a number of people who said the wards they were treated in always seemed full. One woman, Jude*, who was admitted to an Auckland mothers and babies unit in 2019 following severe postnatal depression, said she was discharged before she was ready in order to free up a bed.

“It was like: ‘What about me and my family? We’re here now’,” she said.

Another woman, Janet*, has had several stays in Te Awakura, the main Christchurch acute inpatient unit at Hillmorton Hospital. During one admission, she was moved from her ward to another, unfamiliar unit for the night to free up a bed. The practice, known as a sleepover, is a way of freeing up space if there are new arrivals on an already full ward. Janet, who was feeling suicidal at the time, said it was deeply unsettling.

Sleeping people in “rooms other than designated bedrooms amounts to degrading treatment” and a breach of the UN convention.

– Chief Ombudsman Peter Boshier 

During her admissions to Te Awakura, the nurses were often harried. Even when she was about to have a panic attack, Janet said she always had to wait for medication. The nurses were lovely, but they were often busy with other service users or filling out documentation, she said.

“They were always short on time and could never fully give you what you needed.”

The Canterbury DHB has a policy of only caring for people in designated bedrooms. In the year to November 2020, 104 people across the four wards making up Te Awakura were put in units different to the one they were admitted to for a ‘sleepover’. 

Newsroom asked each DHB if they used seclusion rooms as overflow bedrooms in any of their acute mental health, forensic mental health (for people in the criminal justice system) or intellectual disability units. Eight did. Boshier has previously called out Te Whare o Matairangi, the Wellington inpatient unit, for doing this, describing it as a breach of the UN convention against torture and other degrading treatment. Using seclusion rooms as overflow bedrooms had the potential to cause significant physical and psychological impacts, he said in a statement issued last year.

In their combined OIA response to Newsroom, the Wellington region DHBs said when seclusion rooms were used as extra bedrooms it was in a non-restrictive way to make sure the person did not remain in a less safe environment like the emergency department or a police station.

Capital & Coast mental health, addiction and intellectual disability service executive director Karla Bergquist said high occupancy was a national problem reflecting demand on acute mental health services. The DHB acknowledged work was needed to address high occupancy. 

‘Head-Splitting Pandemonium’ by Michaela K

Planning was underway to invest in crisis respite services, an alternative to inpatient care, including a purpose-built facility in the Wellington region. The DHB was also working with NGO providers to redevelop existing crisis respite services to increase capacity, Bergquist said.

Across their acute mental health, forensic mental health and intellectual disability inpatient units, 13 DHBs admitted to using other rooms, such as whānau and meeting rooms, as overflow bedrooms. Boshier has a problem with this, too. In a 2020 report on Puna Awhi-rua, a Waikato forensic unit, he said that sleeping people in “rooms other than designated bedrooms amounts to degrading treatment” and a breach of the UN convention.

Breaches of the convention appear to be widespread.

Some DHBs, like Counties Manukau, say they won’t use non-designated bedrooms to sleep people over. Counties said instead it would work to find placements in the community, such as respite care, or seek to free up space by discharging inpatients who had recovered enough to be cared for elsewhere.

Because inpatient units are often full, the threshold for admission can be high. Some acutely unwell people can wait hours for an assessment in the emergency department, but still not be admitted. Emma*, who spent time in an Auckland unit last year, said while it was her first inpatient admission, it probably shouldn’t have been.

“There have been other times in my life I’ve presented to the emergency department and said ‘I’m really suicidal’, and they’ve given me valium and sent me home because these wards are at capacity.”

“We’re caught in this really unsafe situation where we need to get people into a contained area in a ward but can’t get them anywhere because of the bed situation.”

Psychiatrists have raised issues, too. The Association of Salaried Medical Specialists (ASMS), a union for senior doctors, provided Newsroom with anonymised interview notes with psychiatrists working in DHBs.

“We don’t have enough acute beds, there is really high occupancy and turnover rates, and we can’t get people in,” one wrote. Another psychiatrist talked about how highly-agitated people were stuck in ED because there wasn’t capacity in the inpatient unit. “We’re caught in this really unsafe situation where we need to get people into a contained area in a ward but can’t get them anywhere because of the bed situation.”

The housing crisis and lack of supported housing and sub-acute facilities was making things worse, a psychiatrist told the ASMS. Some DHBs won’t discharge people into homelessness, meaning they often spend a long time on the ward.

“We have a number of patients who are basically living in inpatient units because there are no other accommodation options,” one psychiatrist said. “It’s really sad that that is their existence.”

Patient A, as he is called in Ombudsman reports, is an intellectually disabled man with complex behaviour who has spent the last 17 years living in a secure forensic mental health unit. At one time, he was spending 15 to 16 hours a day in a seclusion room. District inspectors and the Ombudsman have repeatedly raised concerns that his rights are being breached due to the inappropriate nature of his placement at Christchurch’s Hillmorton Hospital. Forensic units are, typically, for people who have committed a crime. They are not suitable places for people with an intellectual disability. In response to Newsroom, the CDHB said Patient A continued to be cared for in the forensic unit, but was “currently working towards transitioning to care within the community”. Previous attempts for this to happen have been abandoned, in part due to “significant costs”.

Boshier flagged the issue of long stay patients in his 2020 report on Te Whetu Tawera, an acute inpatient unit at Auckland City Hospital. At the time of the 2019 inspection there were 13 people still on the unit considered clinically ready to be discharged, including one who had been living there for 17 months due to a lack of suitable accommodation. Staff expressed frustration at the “non-therapeutic” extra time on the unit.

In response to Newsroom, an Auckland DHB spokeswoman said there were currently four inpatients who had been on the unit for longer than 30 days. Staff were working with them to find suitable accommodation.

Art by Rebecca McNab

ADHB mental health and addictions co-director Tracy Silva Garay said the DHB had started a pilot programme to provide intensive discharge support. The DHB had a housing specialist on-site, meaning service users would be supported into housing and provided with wrap-around care, including social support and continuing mental health care. A similar transition pilot was also underway at Waikato DHB, according to the Ministry of Health. The service would support a minimum of 100 long stay patients over four years.

Having consistently full mental health units takes a toll on staff and detracts from the kind of environment service users want. In interviews with Dr Gabrielle Jenkin, a sociologist at the University of Otago, Wellington, service users said they wanted a relaxing, quiet environment where they could sleep. 

In her first paper published as part of her research on acute inpatient units, Jenkin and her co-authors said staff recognised units should be places offering rest and respite. In reality, they were often chaotic, unpredictable and noisy.

As someone who experienced anxiety, Susan* said she struggled as an inpatient when she was admitted to wards in Palmerston North and New Plymouth.

“There’s always lots of noise and lots of movement and just lots of people around,” she said.

“Basically the whole time I was in the ward my senses would just be extremely heightened. You need to be able to relax in order to get better, so the whole situation was just a bit silly really.”

Do we need more beds?

In a statement provided to Newsroom, Ministry of Health mental health and addiction deputy director-general Toni Gutschlag said the ministry acknowledged specialist services were under pressure, and that DHBs were faced with difficult choices accommodating people who needed to be cared for in inpatient units. 

The ministry was in the early stages of planning a national mental health and addiction services framework. Among other things, this would provide guidance on bed numbers.

Asked if the country needed more, Gutschlag did not say yes or no. The sector was being supported to develop a range of services, she said, before going on to talk about the need to look at alternative options of providing support.

“Providing community alternatives will help to reduce the need for inpatient admissions or enable supported discharges from inpatient services, and is key to supporting people to stay well in their communities and homes,” she said.

Budget 2019 included $455m in funding to create new primary mental health and addiction services in the community. Gutschlag claimed this would reduce demand on specialist services over time by providing early access to services for people with mild to moderate needs.

Garrick, of the NZNO, said her union and others representing staff working in specialist services had been critical of the Government for focusing on the “warm and fuzzy end of things”. Since the $1.9b investment in mental health and wellbeing in Budget 2019, things had improved for people with mild to moderate issues, she said, but not for those with acute illness.

“It frustrates us that we see a Government trying to do some good things, but not prioritising the people who we feel really need that prioritisation now.”

Between 2015 and 2020, successive governments set aside roughly $470m for new mental health facilities and refurbishments. On top of this, Gutschlag said Budget 2019 included $15m over four years for forensic mental health services for adults, $19m for youth forensic services, $8m to improve crisis responses and $44m over four years for specialist alcohol and drug services.

Garrick alleged there seemed to be a “hidden agenda” of governments not wanting to invest in acute inpatient units due to a belief they would eventually no longer be needed, or needed less, due to the shift towards community-based services. She believed this was a mistake. The units would continue to be needed for acutely unwell people, she said, and there needed to be more investment in them.

“They all need to have more of a therapeutic profile.”

Mental health units should provide more than ‘meds and beds’

‘Dilapidated’ mental health units undermining care

*Emma, Jude, Janet and Susan are not their real names. Newsroom has agreed to use pseudonyms to protect their identity. Want to share your inpatient experience? Email oli.lewis720@gmail.com.

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 team@thelowdown.co.nz or free text 5626

Anxiety New Zealand – 0800 ANXIETY (0800 269 4389)

Supporting Families in Mental Illness – 0800 732 825

Oliver Lewis is a freelance journalist with a background in health and employment issues reporting.

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