Chief Ombudsman Peter Boshier is labelling the environment at an inpatient unit at Dunedin's Wakari Hospital, which houses people with intellectual disabilities and mental health issues, as "volatile".
A report released on Wednesday outlines the findings of an unannounced inspection of the Hospital's Ward 10A and Helensburgh Cottage in May last year under the Crimes of Torture Act 1989.
Boshier says the finding that male and female patients - some who have criminal convictions or pose a serious risk - are housed together, is gravely concerning.
"This particular inspection has given me possibly the most concern of any facility that we've inspected, mostly because when we have people in our care, we need to keep them safe," he said.
"We're mixing in this facility – not just patients who are mentally ill and need caring for – but we’re mixing them with those who come from a different forensic stream who have been involved in criminal offending and who are there for a very different reason; it’s not safe."
In addition to the mixture of people with different levels of offending, there's a gender mix too, which Boshier says poses a big safety risk to women.
"Normal good practice is that you supply facilities and treatment according to needs – that’s grade 101 of the way you undertake treatment for anyone.
"What they've done here is to mix up a complexity of needs for some who have low-functioning intellectual disability then you've got a second stream who have committed criminal offences but can't be tried and convicted because of their disability nature but who present a latent threat, that's why they're there.
"It's volatile because you've got people who don't mix in this sort of environment normally and who are there with people who present a risk."
Boshier says the staff at Wakari Hospital describe the situation as "a disgrace".
"The staff were pretty open, more so than I would normally expect, about what they're having to put up with. For staff to describe their own facility as a disgrace is something I have never encountered before, so that must say something about the level of frustration," he said.
"I do want to commend the staff; I do want to say that I am not putting the boot in here to the attempted level of therapeutic care by staff. My inspectors like to be balanced about this and they feel staff are doing everything they can given the mixture of needs and the complexity to try and make this thing work."
Another issue raised in the report was the ward being in critical need of an upgrade and redevelopment.
It says the current environment compromises patient and staff safety as well as patients' dignity.
Boshier said he has "never seen a facility described in this way" in his six years as Chief Ombudsman, adding, "That shows you the level of concern and unacceptability."
He recommended that the ward be rebuilt or, at the very least, upgraded, including remedying ligature points, upgrading soft furnishings, carpets and bedding.
The recommendation is just one of 15 outlined in the report.
Boshier added that the Ministry of Health provides funding for facilities such as Ward 10A but doesn't provide funding for a bigger facility if it's needed.
"It means when they run out of room in their custom-made facilities, they put them all in together, lump them together in this one facility.
"My concern is this is just third world; it's not acceptable in terms of the good, high level that New Zealanders expect."
He said these were some of the issues raised by Boshier's predecessor in 2014, when it was acknowledged that the facility was not fit for purpose.
"The DHB knows it's not fit for purpose and it's extremely frustrating that the Ombudsman is given powers to inspect and comment to make recommendations which are accepted and then nothing is done to actually move the thing forward.
"You'll understand why I begin to get irritated and want to speak out when the integrity of my office is being compromised in this way."
Southern District Health Board acting executive director mental health, addictions and intellectual disability, Gilbert Taurua, told 1News in a statement, "We are appreciative of the thorough review and consideration given to our services at the Wakari and Dunedin Hospital units."
"We found the reports to be reasonably positive, and that they show we are generally providing satisfactory services to our patients and their whānau."
Taurua said the SDHB accepts the recommendations from the report.
"We take them seriously and are working through them. We also acknowledge that some of the recommendations are 'repeat' recommendations, and tackle challenges that are complex and may continue to take some time to resolve.
"What these reports confirm for us, and reassure the community of, is SDHB staff’s continued commitment to patient care and wellbeing in the Mental Health, Addictions and Intellectual Disability Service. We continue to strive to provide a safe and welcoming environment for those requiring inpatient treatment and care."
While Boshier recognised the effort the SDHB is making in "recognising the problem and wanting to do something about it", he wants more action to be taken.
"I recognise their willingness to accept the faults and change but when you think that since 2014, this facility physically, if anything, has got worse, you'll understand why I'm pretty cautious."
He said the Ministry of Health must step up more, adding that the government agency is "missing in action".
In a statement the Ministry of Health said it is aware of the pressure on inpatient mental health services across the country.
"We know this and are working to address it. We acknowledge the issues raised by the Chief Ombudsman’s report, which have also been identified by our Health Infrastructure Unit."
Improving mental health facilities is a priority for the Government, the statement said.
"Significant investment has been made, including in the 2019 Mental Health and Wellbeing Budget."
The ministry says additional funding has been announced, including $2.5m to support the redevelopment of Wāhi Oranga.
"To help meet increasing demand, Budget 2019 invested $77 million over four years in mental health and addiction workforce development."