Eight patients in seclusion for more than 45,000 hours combined in one year

Source: Radio New Zealand

Eight patients in forensic and intellectual disability units were in seclusion for more than 45,000 hours combined in one year, a report reveals.

The patients, who made up only 1 percent of all people secluded in mental health inpatient services, accounted for approximately 36 percent of all seclusion events and about 43 percent of total seclusion hours.

Five of the patients, who were in intellectual disability services, spent on average the equivalent of 283 days of the year in seclusion.

The three forensic service patients spent 160 days on average in seclusion.

Do you know more? Email sam.sherwood@rnz.co.nz

The director of Mental Health and Addiction Services Dr John Crawshaw said in his regulatory report the individuals experienced “prolonged and/or frequent” periods of isolation.

“This raises significant issues around trauma, dignity and human rights, and the impact these experiences have on people and their recovery.”

He has commissioned a review to understand the circumstances of the individuals.

The report also revealed that during the same period a total of 1085 electroconvulsive therapy (ECT) treatments were administered to 105 people who did not have capacity to consent. One person had capacity to consent but refused to consent, and was administered 12 treatments of ECT after an independent psychiatrist provided a second opinion.

The Office of the Director of Mental Health and Addiction Services regulatory report covering 1 July 2023 to 30 June 2024 was released online on the Ministry of Health’s website on Tuesday with no announcement by authorities.

Mental Health Minister Matt Doocey told RNZ he had spoken to Dr Crawshaw about the report and “raised the issue of the delay in its publication”. He also said seclusion was an issue he had been closely looking at “and one I care strongly about addressing”.

The report said it collated data on the use of compulsory assessment and treatment legislation in New Zealand under the Mental Health Act. It also contained data on “related activities” under the Intellectual Disability Care Act and the Misuse of Drugs Act.

Dr Crawshaw said in his role he was responsible for the “general administration of the relevant compulsory assessment, care and treatment legislation” under the direction of the Minister of Health, the Minister for Mental Health and the Director General of Health.

He said overall the data in the report showed the rates of use of compulsory assessment and treatment “remained steady in 2023/24, compared with previous years”.

“The total number of people who have been secluded and the total hours people spend in seclusion have decreased from 2022/23, which are positive trends.”

The report said legally seclusion could only occur under the Mental Health Act or the Intellectual Disability Act.

Dr Crawshaw cited Ngā Paerewa Health and Disability Services Standard as defining seclusion as “a situation where a service user is ‘placed alone in a room or area, at any time and for any duration, from which they cannot freely exit’”.

His analysis of the data for the report revealed that eight patients from three Health New Zealand regional facilities experienced “prolonged and/or frequent periods of isolation”.

The figures revealed that the eight patients were secluded for a combined 45,531 hours across 985 seclusion events.

Three of the patients were from forensic services and were secluded for a total of 11,509 hours across 71 seclusion events.

Five were in intellectual disability services and were secluded for a total of 34,022 hours with 914 seclusion events.

The eight individuals represented just over 1 percent of all people secluded in mental health inpatient services (there were 763 patients secluded in total), but based on the data they accounted for approximately 36 percent of all seclusion events and about 43 percent of total seclusion hours.

Dr Crawshaw said in his report there must be a “clear focus on identifying and addressing the factors that sit behind these experiences in order to ensure the safety and dignity of people in the care system”.

“The Office of the Director of Mental Health is undertaking deeper analysis of the circumstances and factors that led to these prolonged or frequent periods of seclusion and the interventions in place to address them. The Office will work with Health New Zealand on this initiative.”

The individuals were subject to compulsory care under mental health, intellectual disability, or criminal procedure legislation.

Dr Crawshaw said inquiries would look at confirming the accuracy of reported seclusion data, assurances the individuals had safeguards in place to protect their rights and that services were meeting the expected standards for seclusion.

There would also be a focus on getting assurances that services were taking “active measures to reduce and eliminate seclusion”, and the reasons for the extended seclusion hours.

“After receiving the information, the Director will ensure it is reviewed and will consider recommendations for action by the service providers and any areas that require escalation to other agencies.”

In total, across the overall mental health inpatient services 73 percent of seclusion events lasted under 24 hours, with 16 percent lasting over 48 hours.

In adult inpatient services there had been a 24 percent decrease in hours spent in seclusion since 2022/23 and a 73 percent decrease since 2009. There had also been a 48 percent decrease in the number of people secluded since 2009.

The report also looked at ECT, a “therapeutic procedure that delivers a brief pulse of electricity to a person’s brain to generate a seizure while they are under anaesthesia”.

Dr Crawshaw said ECT could be an effective treatment for depression, mania, catatonia and other serious neuropsychiatric conditions.

“It can happen only if the person receiving it consents or in carefully defined circumstances without their consent.”

In the 2023/24 period nearly 300 people received ECT, with services administering more than 3500 treatments of ECT.

Dr Crawshaw said that under the Mental Health Act, a person could be treated with ECT if they consented in writing or if an independent psychiatrist appointed by the Mental Health Review Tribunal considered the treatment to be in the person’s interests.

Nearly 1100 treatments were administered to 105 people who did not have the capacity to consent.

“One person had capacity to consent but refused to consent, and was administered 12 treatments of ECT after an independent psychiatrist provided a second opinion.”

The report said that in total, nearly 11,500 people were subject to the Mental Health Act in the 2023/2024 period. Of those using specialist mental health and addiction services, 93.5 percent engaged voluntarily.

“About 5883 people were subject to either compulsory assessment or compulsory treatment under the Mental Health Act on the last day of the 2023/24 year.”

Dr Crawshaw acknowledged that the report, which looked at data nearly two years old, had been delayed in being published.

He said there were two main reasons.

“First, the data is complex. Second, some regulatory data are still reported to the Ministry via manual processes, which creates further time lag for receipt and quality assurance processes.”

In response to questions from RNZ, Doocey said he had spoken with Crawshaw about his report and had “raised the issue of the delay in its publication”.

“New Zealanders rightly expect that mental health services are being monitored so we can provide assurance that people undergoing compulsory assessment, care and treatment are receiving the right support.

“This monitoring occurs regardless of whether a report is being finalised, and I would expect any urgent issues identified to be addressed promptly rather than waiting for the report to be completed.”

He said seclusion was an issue “I care strongly about addressing”.

“Each individual case is a clinical decision, and I expect that the appropriate processes and assessments are followed.

“I am clear that seclusion should be used only as a last resort. The Mental Health Bill currently before Parliament seeks to make changes to reduce its use. This includes requiring the person in charge of a service to report annually to the Director-General on the steps taken to eliminate the placement of people under compulsory care in seclusion.”

In relation to ECT, Doocey said he had sought assurance from Crawshaw that the decisions around its use were the “right clinical decisions to make”.

“The Mental Health Bill also seeks to introduce stronger safeguards around the use of ECT, including ensuring that the second opinion that’s needed, would be required to have expertise in ECT.”

In response to questions from RNZ, a Ministry of Health spokesperson said Dr Crawshaw was “concerned” about the data regarding seclusion and had commissioned a review.

“To understand the circumstances relating to each of these people, including ensuring rights protections, and verifying that services meet the required standards.

“As part of the review, all individual treatment planning and circumstances will be scrutinised, and the Director of Mental Health will consider recommendations or escalate concerns to other agencies as appropriate.”

The review would also examine the reasons behind the extended seclusion hours and identify any barriers to reducing and eliminating seclusion.

This work was expected to be completed by 31 May.

In relation to ECT, the spokesperson said it could be an effective treatment for serious neuropsychiatric conditions.

“The current use of ECT differs substantially from the electric shock treatment that was used in the past. In New Zealand, it can happen only if the person consents in writing, or in carefully defined circumstances without their consent.

“For ECT to take place without consent, an independent psychiatrist must provide a second opinion on the treatment plan and consider the treatment to be in the person’s interest.”

RNZ also asked about the delay in the report being published.

The spokesperson said the data relating to mental health and addiction services and treatment was “complex and requires thorough analysis and review to ensure it is correct”.

“This process takes time. Some data is still reported manually which requires additional review, and creates a further delay to publishing.

“The data is representative of private information relating to the care and experiences of individuals. It’s important that we treat the information with care and integrity and take the time to fully understand and assess the data provided to us.”

Health New Zealand (HNZ) national director of Mental Health and Addictions Phil Grady said in a statement to RNZ that HNZ “welcomes” Dr Crawshaw’s report.

“Which highlights whilst there has been an overall reduction on seclusion there are also a small group of people who experience seclusion for extended periods of time. We will fully support any further reviews Dr Crawshaw wishes to undertake following the publication of the report.”

HNZ expected seclusion to be only used as a “last resort and after careful consideration of all available options of care”.

“As such, the process to minimise the use of seclusion in our facilities is ongoing and we continue to have close oversight of this practice, including having up to date seclusion use data via a dashboard, focusing on how we improve our environments and importantly, how we train and support our staff.”

In relation to ECT, Grady said it was an “effective short-term treatment” for severe depressive illness, and certain other forms of serious and potentially life-threatening mental illness.

“People offered this treatment often are extremely unwell, at high risk of harm to self or high risk of extreme neglect leading to life threatening consequences after a full clinical assessment.”

He said people could choose to have ECT treatment on a voluntary basis and it could also be provided compulsorily under the Mental Health Act.

“In addition, if the person is not competent to consent or the whānau are not supportive of ECT and it is considered a life-preserving intervention, a second medical opinion is sought from a Mental Health Act Tribunal-approved psychiatrist.”

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– Published by EveningReport.nz and AsiaPacificReport.nz, see: MIL OSI in partnership with Radio New Zealand