An inquiry commissioned by the Director of Mental Health found that essential safeguards were missed, resulting in an 11-year-old girl being mistaken for an adult mental health patient, then twice being restrained and injected without consent.
Director of Mental Health Dr John Crawshaw extends his sympathies to both the child and her whānau.
To help prevent this happening again, the inquiry recommends clearer processes for confirming who patients are, better training for frontline staff, stronger communication and record‑keeping, more support for patients and whānau, and improved monitoring and follow‑up across services.
‘No parent would want their child to be mistaken for someone else, or mistaken for an adult, particularly where that mistake leads to restraint and treatment that should never have occurred’, says Dr Crawshaw.
‘I recognise the complexity of this case, the challenging conditions staff were operating under, and their good intentions. However, the outcome was unacceptable’.
He says there are safeguards intended to protect patients within mental health services, but these were not consistently applied in this case.
‘The failure to accurately confirm the child’s identity was the key and central failing,’ says Dr Crawshaw.
‘This failure undermined subsequent decision‑making and was compounded by staff not being aware of important policies, key decisions not being documented properly, breakdowns in communication between teams, and insufficient medical assessment.
The inquiry did not find a lawful basis for the two times the child was restrained and medicated without consent, even if clinicians had been treating the adult patient the child was mistaken for.
‘This inquiry focused on systems and practice, rather than focusing on individual blame,’ he says. He notes there are several other reviews of this case including by the Health and Disability Commissioner.
‘I have shared the inquiry report with the Health and Disability Commission and I have met with and written to Health New Zealand seeking a system response to the recommendations,’ he says.
Dr Crawshaw says Heath NZ has developed an action plan to address the recommendations and has committed to monitoring and reporting on progress.
‘This provides assurance that the issues identified are being addressed,’ he says. ‘This distressing case highlights the importance of applying safeguards consistently, every time, to protect patients across the health system and maintain trust in mental health services,’ Dr Crawshaw says.
