The Health and Disability Commissioner has found Te Roopu Taurima O Manukau Trust breached the Code of Rights over the care of a woman placed in its secure facility in 2019, with one staff member found to have struck her during a restraint and another found more likely than not to have supplied aerosol cans she later abused.

Deputy Commissioner Dr Vanessa Caldwell’s decision examines a six‑week period in 2019 when “Miss A” was temporarily housed at Te Roopu Taurima under the High and Complex Framework while awaiting a court‑ordered assessment. She was later found not to have an intellectual disability and was released after court.

Caldwell found Te Roopu Taurima breached Right 4(2) of the Code for failing to provide services that complied with professional and other standards. Independent advisor John Taylor identified system and practice issues, including:

• threats used by multiple staff to manage behaviour
• a behaviour plan that was too general to guide care
• gaps in security guidance, incident reporting and follow‑up
• emphasis on restraint minimisation rather than avoidance
• weaknesses in medication management.

During the placement, more than 20 incidents were recorded, including six absconding events, self‑harm, property damage and assaults on staff. Police were called on several occasions.

One incident on a single evening became central to the findings. As staff tried to redirect Miss A back to her room after repeated absconding attempts, support worker Ms E struck her in the face while Miss A was being restrained. An external investigation commissioned by the provider concluded the strike occurred; the level of force could not be determined. Caldwell found Ms E breached Right 4(2) for failing to provide services consistent with professional standards. Ms E also breached Right 10(3) for failing to engage with HDC’s investigation despite repeated attempts to contact her.

Support worker Ms D was found to have used an unauthorised restraint during the same episode and to have omitted key details — including the strike — in the incident report. Caldwell found Ms D breached Right 4(2) and, for her limited engagement with the investigation, Right 10(3).

Senior support worker Ms B was found to have breached Right 4(4) for actions that increased the risk of harm. The provider’s external inquiry and text messages between Ms B and Miss A’s mother led HDC to conclude it was more likely than not that Ms B supplied Miss A with aerosol cans as leverage to recover stockpiled razors and medication. Ms B told HDC she did not supply the cans; Caldwell noted no evidence was provided to support that claim and accepted the external investigation’s conclusion. Ms B later provided submissions to HDC but had long periods of non‑engagement; Caldwell issued adverse comment on that.

Medication management was a recurring concern. Miss A hoarded quetiapine after a staff member repeatedly provided extra PRN doses on request over a week, leading to 900mg being returned. In a separate event, she barricaded herself and took an unknown quantity of quetiapine after grabbing a box from a locker; she was taken to hospital for observation. Caldwell issued adverse comment on the provider’s medication practices, particularly for casual and rostered staff, noting a requirement that all staff be competent in medicine management and error detection.

Caldwell accepted that on occasions when acute harm was identified — including self‑inflicted cuts and solvent abuse — staff sought appropriate medical help, including ambulance, Police and crisis teams, and that Miss A was taken to hospital when indicated.

The decision also records that staff sometimes threatened to involve Miss A’s father or cancel visits to manage behaviour. Caldwell described this as a systemic issue pointing to gaps in de‑escalation training and guidance.

Te Roopu Taurima told HDC the placement was complex because its secure service is designed for people with intellectual disabilities, and Miss A ultimately did not meet that threshold. The provider said the three staff criticised no longer work there. It also outlined changes since 2019, including:

• digital incident reporting and a linked learnings register
• a structured critical‑incident debrief process
• medication policy updates and competency reviews
• annual MAPA refresher and Positive Behaviour Support training
• immediate escalation of critical incidents to senior management
• automatic restraint‑coordinator review of any restraint use
• security assessments and facility upgrades
• regular policy quizzes for staff.

Caldwell recommended formal written apologies from the provider and from Ms B, Ms D and Ms E to Miss A, and that the three complete HDC’s online complaints‑resolution module.

A copy of the anonymised report will be sent to Whaikaha | Ministry of Disabled People and the Ministry of Social Development, and published on the HDC website for education purposes.