Staff at a psychiatric facility for acutely unwell teenagers worked in "dangerous" conditions and endured so much stress that it was "severely impacting their physical and mental health", according to a health and safety notice obtained by the Herald.

Concerns about the safety of patients and employees at the Regional Rangatahi Adolescent Inpatient Service (RRAIS), a 12-bed unit at Kenepuru Hospital in Porirua, came to a head late last year, when a "provisional improvement notice" was filed accusing the Capital & Coast District Health Board of breaching its duty of care to employees under the Health and Safety at Work Act 2015.

According to the notice, issued by a health and safety representative in late November, the psychiatric unit was so chronically understaffed that inexperienced workers were put into risky situations that they weren't equipped to handle — including keeping watch over young people who are at high risk of suicide or self-harm, "placing both at risk".

Most shifts didn't have enough staff trained to "de-escalate" potentially violent interactions, the notice claimed, while the team leaders couldn't fully focus on their roles because they so often filled in for others. Nurses constantly worked overtime and double shifts to cover gaps in the roster.

"This is exposing staff to burnout, higher likelihood of a serious incident occurring to staff or client, increased likelihood of medication errors and impacts on overall therapeutic milieu and running of the unit," the document said.

The DHB contested the notice, partly because there were "no short-term answers" to address a national workforce crisis in mental health, but held a series of meetings with employees and unions which have led to some improvements in recent months. However, the facility still faces serious staffing challenges — as do mental health services across the country.

The situation at RRAIS was first exposed by the Herald last week in an ongoing investigation into the state of mental health services. It starkly illustrates how public providers across the country are struggling to cope with a rise in people in mental distress at the same time as confronting a severe workforce crunch years in the making.

On Thursday, the Herald reported that two separate inspections in the past year and a half by the office of the Children's Commissioner found a multitude of problems at RRAIS relating to staffing, the physical condition of the unit, and the wellbeing of patients.

In the first report, based on a surprise inspection in March 2021, the Children's Commissioner said the facility was "cramped, rundown, and decaying" and so chronically short of experienced employees that staff feared it would lead to "serious injury or death".

'Labour lacks urgency towards mental health'

Three years after the Labour Government's announcement, only one out of 13 specialist mental health inpatient facility upgrades has shovels in the ground, National's Mental Health & Suicide Prevention spokesman, Matt Doocey, says.

"As part of Budget 2019, the Labour Government announced $350 million of crown funding to go towards upgrading 13 mental health in-patient facilities. To date, only 2 per cent has been spent and only one facility has shovels in the ground.

"Our most vulnerable Kiwis are left with nowhere to turn as mental health inpatient facilities are rotting from the inside out, are at consistent over-occupancy, and operating outside of patient safety clinical guidelines.

"For years, the mental health sector and the public have called on the Government to take urgent action and upgrade our specialist services. We are yet to see a plan from the Health Minister on how he will change the course of the trajectory for our worsening facilities.

"In June 2021, Andrew Little told media he was 'extraordinarily frustrated' that the Government's $1.9 billion mental health package wasn't going towards services and that less than 1 per cent had been spent.

"A year on and the Minister has failed deliver any better outcomes for Kiwis because he has been too focused on his ideological-driven health restructure.

"Labour promised to transform the mental health system but sadly, for many Kiwis, mental health services are more out of reach now than when Labour first came into office. Their lack of urgency to commence construction on these specialist facilities has now left Kiwis who require these acute levels of care at odds of where to go.

"Simply announcing funding with good intentions doesn't solve any of the issues facing a declining mental health sector. What our vulnerable Kiwis need is a well-managed plan to execute change. Unfortunately we lack a government and a minister who prioritises mental health."

The Herald has also obtained numerous documents from the DHB and other sources which have not been made public before now and provide new insights into the extent of the problems at the unit. They reveal that the safety issues provoked a confrontation between staff and DHB executives late last year.

In September, 27 nurses and support staff wrote to union representatives at the New Zealand Nurses Organisation and Public Service Association warning of the risks of understaffing and unsafe physical environment.

"We as a team are trying our best to provide quality care for our youth," they wrote. "We are committed to each other and this is one of the only positives we currently have. This team is stretched and we need support from senior management.

"The DHB has a duty of care to their staff to provide a safe working environment and for the reasons outlined above they are not meeting this. This makes our work of caring for vulnerable youth so much more challenging."

That month, the DHB produced an assessment classifying the problems at RRAIS as a high and unacceptable risk, citing ongoing vacancies and an unsuitable environment as constraining the service's capacity to provide safe care for patients.

Deteriorating working conditions could, it said, lead to increased stress for employees, union action, breaches of health and safety legislation, "unplanned service restrictions with no therapeutic interventions for clients", failure to meet performance targets, and "adverse publicity and reputational damage".

In October, senior managers from the DHB's mental health service met union representatives to discuss the safety issues. But a month later RRAIS's acting team leader wrote to those executives saying there'd been "little change in our situation" and staff representatives would be issuing a provisional improvement notice.

That notice — which one union representative told the Herald was a "last resort" — said the staff had achieved "little traction" in their talks with management. "No changes have occurred and there has been no appreciable improvement to the health and safety of staff and patients," the notice said.

"These dangerous working conditions have still not been resolved. Staff are working under increased pressure and stress, severely impacting their physical and mental health due to excessive demands. This has been documented and raised through daily reportable events with insufficient additional support to mitigate the risk."

In November, DHB managers held a meeting with around 30 RRAIS staff.

The feeling among employees, according to the DHB's formal record of the meeting, was that management's response to their concerns had been "disappointing and failed to acknowledge the distress the team were under".

While management had pledged to make improvements, employees were frustrated that these were not happening quickly enough. Staff spoke of "feeling at risk" because of the shortage of experienced nurses, and worried that this would continue while the DHB took time to recruit replacements.

"There is concern that the physical and mental wellbeing of staff and rangatahi is not being heard, staff are losing confidence in that issues will not be resolved," the meeting notes state.

In December, Karla Bergquist, executive director of Capital & Coast DHB's mental health service, wrote to RRAIS staff representatives acknowledging their concerns and assuring them that "we have taken these concerns very seriously".

Maintenance work was already under way to improve the state of the unit, Bergquist said, and a wider refurbishment was planned. The mental health service was doing all it could to fill staff vacancies and had submitted a business to increase the budget for full-time employees at the unit.

In February, an action and improvement plan created by the DHB recorded progress on several fronts. Some renovations to the facility had been carried out, although this had been disrupted by Covid-19. Handheld safety alarms had been installed. Staff were being trained in de-escalation techniques and there had been a reduction in the number of patients secluded or physically restrained.

However, staffing pressures remained because of a critical national shortage of nurses and other experienced mental health professionals.

In a statement, Bergquist said the staffing challenges at RRAIS are being felt across the mental health system. "Inpatient volumes have also increased and acuity is higher, meaning there are more rangatahi with complex needs."

Amid these pressures, she said, the health authority (Capital & Coast is now part of the combined Te Whatu Ora/Health New Zealand, after a national restructuring took effect this month) is committed to "continuously improve the quality of service we provide" and takes the safety of staff and patients seriously.

The authority has implemented numerous short-term and long-term measures in recent months to improve RRAIS, Bergquist said, including more therapeutic activities for patients, allocating new nursing graduates to the facility, and stepping up its recruitment campaign.

"The RRAIS leadership team continues to work with staff to find solutions that ensure safe staffing," Bergquist said.