A woman supporting a friend through a mental health crisis tried to tell Emergency Department staff she was afraid he would hurt her.
She asked to leave the room, even giving a note to a nurse listing her friend’s concerning behaviours and stating that when he becomes unwell, he tries to hurt and “kill” her.
It included a request that he not be released.
She was told the note would be read later and was encouraged by hospital staff to stay in the room without security and support the man.
The man went on to assault her in the closed room, leaving her with injuries to her arms, hands and head.
Police were never called by hospital staff and were only informed about the assault when the woman’s daughter contacted them.
The woman complained to the Health and Disability Commissioner about the April 2022 incident and the hospital’s handling of it.
In a decision released today, deputy commissioner Dr Vanessa Caldwell was critical of Health NZ and found it breached two rights of the Code of Health and Disability Services Consumers’ Rights.
“I accept that [the woman] had significant and warranted concerns about her safety around [the man] in the ED and that staff did not adequately address these concerns.”
Woman assaulted in whānau room
It was April 27, 2022, when the woman attended Hutt Hospital ED with her male friend who was experiencing a mental health crisis.
At the time, the man was boarding with the woman and her two children.
Neither the woman nor the man is named in the decision.
The woman told the HDC she was concerned about her friend’s deteriorating mental health and that he went to the ED earlier that morning but was later discharged home.
She became increasingly concerned about his behaviour and accompanied him to the ED again at 10pm.
Health NZ told HDC that, on arrival, the woman consented to being the friend’s support person while he awaited review, but this was not documented.
They were placed in the whānau room, which Health NZ said is a private room adjacent to the reception desk where the triage nurse, receptionist and a security guard sit.
The woman told the HDC they were left alone in the room and that she began to feel unsafe. She said there were no security guards outside the room.
She had reported to two different nurses that she felt unsafe but was asked to stay to support her friend.
She then wrote a note expressing her concerns and gave it to the overnight ED registrar when he entered the room. She was told the note would be read later and was encouraged to stay and support her friend.
There was no documentation in the records of these conversations or of the note being given or its contents. Health NZ did not provide statements from the nurses involved beyond what was included in the clinical records.
The woman provided HDC with a photograph of the note she handed to the ED registrar.
She also provided videos she had taken while they were waiting in the room to demonstrate his behaviour at that time.
At 12.21am the ED registrar documented that he had reviewed the man with the woman present, who had advised that he had been agitated at home and she “feels unsafe with him around due to previous violence at home when [he] is in this state”.
The registrar told HDC that the woman expressed discomfort about her friend and what he may do. However, he considered the ED to be an implicitly safe place where any violent behaviour “could be addressed before it escalated”.
The ED registrar said he regrets not giving greater consideration to the man’s risk to others and ensuring he was more closely monitored.
The man’s behaviour continued to escalate until he physically assaulted his friend.
Clinical notes indicated that, on hearing the altercation, staff entered the room, activated the duress alarm, and removed the woman to a bed in the ED.
The woman told the HDC she repeatedly told hospital staff it felt like her “head was caved in” and it was sore and she was dizzy.
There was no further investigation into whether the woman had suffered a concussion.
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The ED registrar told HDC that, although the woman did not have any outward signs of concussion, he should have put greater emphasis on the provision of information on recognising and treating concussion.
She was discharged home with pain medication. She was asked whether she would like police to take her home, but she said she was disoriented from the assault, so walked the 10-minute walk home alone.
A Security Staff Incident Report Form states that the man absconded from the ED at 1.35am and the registrar documented that the woman had been informed and police notified.
The report said that police located the man and returned him to the ED sometime between 2.30am and 2.55am, after which he was voluntarily admitted to Te Whare Ahuru inpatient unit, a 24-hour mental health assessment and treatment service.
On May 3, 2022, he was discharged from Te Whare Ahuru and taken into police custody.
Woman ‘should have been believed’ – Health NZ
Health NZ’s Violence Intervention Programme Leaders (VIPLs) subsequently conducted a review of the woman’s case.
It found that the woman should have been believed and a safety response actioned when she advised staff that she felt unsafe, and that ED staff should have notified police immediately after the assault occurred.
It also found ED staff should have completed an Intimate Partner Violence Risk Assessment and Intervention Form.
“In my view, by failing to respond appropriately to [her] expressions of feeling unsafe; allowing her to walk home alone after the assault, when [his] whereabouts were unknown; failing to appropriately assess her for a possible head injury; failing to provide concussion safety netting advice; and for not completing an incident report after the assault, Health NZ failed to provide care to [her] with reasonable care and skill.”
Health NZ implemented changes in late 2023 as a result of a separate review of an unrelated event in 2020.
It included installing swipe card access for the whānau room, a new door between the whānau room and the waiting area and significantly strengthening security coverage in the ED.
Caldwell further recommended that Health NZ provide a written apology to the woman and update the relevant policies to guide staff in managing a witnessed assault in the ED and use an anonymised version of this report to provide training to staff on the updated policies.
Sarah Fenwick of Health NZ said in a statement she acknowledged the impact the incident had on the woman and her whānau and apologised.
She said Health NZ accepted the Commissioner’s recommendations which it would address by December 30, 2026.
Brianna McIlraith is a Queenstown-based reporter for Open Justice covering courts in the lower South Island. She has been a journalist since 2018 and has had a strong interest in business and financial journalism.
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