Iwi boards call for independent advocacy after autistic 11-year-old mistakenly sedated

Three Iwi Māori Partnership Boards are calling for independent advocacy for whānau from the outset of serious incidents, after an 11-year-old was mistaken for an adult, restrained and injected with drugs.

The girl had been taken to Waikato hospital by police after she was spotted walking in the middle of the road and climbing a bridge.

She had been mistaken for a missing 20-year-old mental health patient.

Te Tiratū , Te Taura Ora and Te Moana a Toi Iwi Māori Partnership Boards, which represented 646,000 Māori, said the findings released on Friday into the treatment the 11-year-old tamaiti Māori and tāngata whaikaha autistic child exposed "profound avoidable failures across Police and health systems breaching Te Tiriti o Waitangi," as well as international United Nations conventions.

They said it also breached the Health and Disability Code of Conduct, Pae Ora, and mental health legislation.

Te Tiratū board member Dr Mataroria Lyndon described what happened was shocking.

"My aroha to the whānau and the tamaiti, or the child, who has gone through and been impacted and traumatised, not only from what's happened, but also, over the past 15 months, acknowledging the multiple inquiries and investigations that have been underway," he said.

"The findings [...] have been even worse than I had anticipated, in terms of the systems that have failed."

In a statement released alongside reports by the Health Ministry and the Health and Disability Commissioner (HDC), the child's family says they cannot understand how the non-verbal child was mistaken for a 20-year-old woman, handcuffed by police and admitted to an adult mental health ward where she was restrained and twice injected with sedatives.

The ministry investigation has found the central and key failing was hospital staff not following the formal process for confirming the identity of people who are unable to say who they are.

Not all staff were aware of what the policy was.

There was no lawful basis to restrain and medicate the patient, even if she had been the 20-year-old they thought she was, it said.

Lyndon said a more whānau centric approach was needed.

"I think it really is about being more whānau centred in this approach, to support the whānau and any other whānau where they face particular situations where they need greater advocacy."

What support a whānau was given as they went through not only the serious event itself but also the the inquiry process was also really important to address, Lyndon said.

He said they were calling for all recommendations from the reports to be implemented, as well as the role of an Iwi Māori Partnership Board to be recognised.

The board was concerned by the lack of information they were given, Lyndon said.

"We also have a statutory role under Pae Ora in terms of monitoring Health NZ, and so we're really incredibly concerned about the lack of timely information for us as part of our role as a monitor," he said.

In a statement, Health NZ said it had accepted the recommendations of the Health and Disability Commissioner's report and the Section 95 inquiry.

The executive national clinical director, Dr Richard Sullivan, said the "distressing" event was caused by failures in the admission and patient identification systems.

"We should not have relied on an initial identification by police who brought this young person to us," he said.

"We recognise this has been a very traumatic event for this young person and their whānau and have apologised to them again and continue to offer them support."

A national restraint governance group had also been set up to promote safe and standardised restraint minimisation practices across Health NZ, Sullivan said.