Summary Report: Section 95 inquiry into the treatment of a person at Waikato Hospital

In April 2025, the Director of Mental Health initiated an inquiry under section 95 of the Mental Health Act into the situation that occurred in March 2025, where a person was misidentified and subsequently compulsorily treated at Waikato Hospital. The summary report on the inquiry and its recommendations is now complete. The Director of Mental Health has written commentary on the section 95 inquiry report.

Section 95 inquiry report

The Section 95 inquiry, commissioned under the Mental Health (Compulsory Assessment and Treatment) Act 1992, examines the circumstances in which an 11‑year‑old girl was misidentified as an adult patient and received compulsory mental health treatment without lawful basis.

The inquiry finds that key safeguards intended to protect patients were not properly applied, with the failure to confirm the patient’s identity identified as the central issue. It also identifies contributing factors including gaps in processes, communication, documentation, and staff awareness of relevant requirements.

The report makes recommendations to strengthen systems, policies, and practice to help prevent a similar incident occurring again.

Director of Mental Health response

The Director of Mental Health’s response sets out how the findings of the inquiry have been considered, alongside the findings of the Health and Disability Commissioner’s investigation.

The Director concludes that further action is required at a national level to ensure essential safeguards are consistently applied to protect the rights of people receiving compulsory care.

Health New Zealand has developed an action plan in response to the recommendations and has committed to monitoring and reporting on progress. The Director will continue to oversee this work to support system-wide improvement and strengthen safeguards for patients.