• Findings of a Health New Zealand investigation into a mistaken identity incident involving an 11-year-old girl have been released. 
• The child - understood to be autistic and non-verbal - was misidentified as a 21-year-old before being handcuffed and drugged. 
• Police and Health NZ today issued fresh apologies over failings. 
• New procedures to handle unidentified people come into force next week. 

Health New Zealand has acknowledged “significant failings” and apologised for the “traumatic experience” an 11-year-old girl who was handcuffed, restrained at a mental health facility and injected with antipsychotic drugs in a case of mistaken identity.

Findings and recommendations following a review into the incident - first reported by the Herald and slammed by Prime Minister Christopher Luxon as “unacceptable” - were released at midday admitting “significant failings” by health staff.

Health New Zealand Te Whatu Ora confirmed the young girl was misidentified as a 20-year-old woman, today said its staff initially thought she resembled a child that may have a disability, but assumed it was a mental health-related incident.

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“The Rapid Incident Review confirms several failings contributed to the distress and trauma experienced by this young person and their family. Once again, and on behalf of Health NZ, I offer our deepest apologies,” chief clinical officer Dr Richard Sullivan said.

Among the findings of the review, Health NZ stated it was assumed the girl was displaying potential mental health symptoms, resulting in a mental health crisis assessment and home based treatment (CAHT) team being called before she was reviewed first by the Waikato Hospital emergency department.

The CAHT team initially considered the patient resembled a child and may have a disability, but trusted police judgement on the girl’s identity as a woman in her 20s.

It also said current Waikato Hospital identification processes were inadequate for a situation like this.

The young girl was medicated in the admission area before being transferred to the intensive psychiatric care unit. She declined oral medications, so staff twice injected her with a medication that is “rarely administered to children”.

“Staff were working on the assumption that they were administering medication to an adult, not a child... The medication is not first line choice in adults but was given due to a shortage of supply.”

Sullivan said recommendations outlined in the review – which would be implemented next week – included;

• Apologising to the girl and her family and provide appropriate support to understand the findings and recommendations. 
• Undertaking a rapid review to identify unidentified patients, particularly those with any kind of communication difficulty. 
• Ensuring all Emergency Departments undertake medical reviews on unidentified patients. 
• Establishing a national restraint group to develop best practice for physical restraint, medication restraint, monitoring after sedation, de-escalation processes and staff training. 
• Reviewing criteria and procedures for admission to psychiatric intensive care units. 
• Reviewing workforce resourcing in the Waikato District’s mental health inpatient unit. 
• Ensuring cultural support is offered to mental health patients as early as possible in the admission process. 
• Engaging cultural and disability services in the actioning of relevant recommendations. 

Sullivan said Health NZ continued to provide “appropriate and on-going support” to the young girl and her family. 

“Our staff endeavour to provide high standards of care and we want to ensure what happened in this particular case cannot happen again.” 

Police misidentified young girl as woman in 20s, ‘despite genuine attempts’ 

Waikato Police have also released preliminary findings of an internal district review, saying the matter has been self-referred to the Independent Police Conduct Authority. 

Its review found it was “reasonable” for police to place the young girl in handcuffs on arrival at Waikato Hospital “to protect her own safety and the safety of staff”. 

It said police misidentified “despite genuine attempts to confirm her identity”. 

“What we know at this stage is that the misidentification occurred despite the genuine efforts of our staff to identify the female. However, we also know that our processes can be improved to further reduce the risk of an incident like this recurring,” said Assistant Commissioner Sandra Venables. 

Police earlier told the Herald the girl was identified as a missing mental health patient in her 20s after a photo taken of her at the facility was distributed to a list of police staff and subsequently a mental care provider. 

“We acknowledge that the events have been distressing for [the young girl] and their family. Waikato Police have met with the family and apologised for the misidentification.” 

Venables said the broader review was still in the information-gathering phase. 

Shocking incident that saw girl injected with antipsychotics 

Police were called to Fairfield Bridge in Hamilton about 6.40am on March 9, after a person described as a female in her 20s was seen walking in distress. 

Acting Waikato district commander Superintendent Scott Gemmell last week told the Herald the 111 caller reported the woman appeared to be intoxicated and that city cameras captured her climbing up the rails of the bridge. 

Police were called to the Fairfield Bridge in Hamilton on Sunday, March 9, after a person described as a female in her 20s was seen climbing on to the railings. Photo / NZME 

Police units, including a police boat, responded immediately, fearing her safety. 

“She was repeating the questions that the officers had asked her. They weren’t able to form an identification of her at that point, but she looked by virtue of the wider circumstances of someone that needed care and it progressed from there,” Gemmell said. 

The Herald understands the girl is autistic and non-verbal. 

Police were concerned she was suffering from a mental health episode and took her to Waikato Hospital’s Henry Bennett Centre for assessment where she was handcuffed and later understood to have been injected with two doses of haloperidol, an antipsychotic medicine. 

About 6pm – some 12 hours after police responded to the bridge incident – a woman reported to police that her 11-year-old daughter was missing. 

Deputy chief executive for Te Manawa Taki (Central North Island region) Cath Cronin said Health NZ would review every step taken while the young girl was at the facility, “including any medication or treatment given to try to ensure this never happens again”. 

“Our staff work extremely hard to provide the best care they can for people coming into our care and are deeply disappointed this young person was incorrectly identified.” 

Waikato Police was also conducting an internal review. 

Luxon described the incident as “incredibly concerning” and said ministers were informed following a Herald query two weeks after it occurred. 

“As a parent, you identify with what is a horrific set of circumstances that has happened and it’s just incredibly distressing and concerning, massive amounts of empathy and concern for her and her family.” 

Mental Health Minister Matt Doocey last week called the incident “hugely concerning” and said, “it might be unprecedented”. 

“It does defy belief... I still don’t understand how an 11-year-old has been confused for a lady in her 20s,” Doocey said. 

He confirmed the girl was administered two doses of antipsychotic medication “over the course of the day”. 

“It’s every parent’s worst nightmare and that’s why I’ve sought assurance of the welfare of the 11-year-old, I’ve been given that assurance that she is doing well.” 

He said his office wasn’t informed earlier because there was no escalation of the incident within Health NZ itself, meaning its acting chief executive wasn’t told either. 

Benjamin Plummer is an Auckland-based reporter who covers breaking news. He has worked for the Herald since 2022.