The whānau of an 11-year-old girl with autism who was mistaken for an adult mental health patient, before being restrained and injected with anti-psychotic drugs, have spoken out for the first time.
It comes as two new reports – one from the Ministry of Health’s Director of Mental Health and the other from the Health and Disability Commission – conclude some actions against the child were unlawful and her rights were breached.
The girl, who is Māori, was mistaken for a 20-year-old woman and, although she acted in a childlike manner, was restrained and medicated as an adult despite showing no risk of immediate harm to herself or others.
Sister disgusted and 'sick to my stomach'
The sister of the 11-year-old girl recalled the events from last year as they started to piece together what happened.
“I remember being so disgusted and I felt sick to my stomach getting more information about what happened, and then I remember being angry, like, really angry.”
After reading the details in the reports, she said it was hard to come to grips with how everything unfolded.
“It sounds like there was a lot of opportunity to properly identify her and a lot of people actually state that they think that she is autistic and not a mental health patient.
“I think knowing that it was really close to being handled properly, and then it ending the way it did, is really hard for me to come to terms with.”
She said her sister has a lot of trouble feeling safe going outside and recovery has been “really hard”.
It has taken a toll on the rest of her whānau too.
“Me and my siblings, we've all been really angry through it all, but my mum, I think she's [taken] it really, really hard because she became really different afterwards.
“She was just so tired of everything, and she did a lot of blaming herself, and she wasn't talking as much. The rest of us have just been angry, and we still are.”
She said the whānau received several visits from “a lot” of people in the aftermath of the incident.
“It was to a point where it was just a bunch of people going in and out of our house and asking questions and I know my mum especially was just so tired of it.”
She said she was glad they were finding out “exactly” what happened to her sister with the release of the two reports, but they were a tough read.
“There was a point where I couldn't keep reading because it just made me feel sick to my stomach and angry, and I just, I couldn't sit there and reading in detail the treatment that she went through.”
She still doesn’t understand why so many things were ignored and believes those who made decisions on the day have yet to take accountability for what unfolded.
“They were back and forth about whether or not they have actually done anything wrong and it isn't until very recently, which is a long time later, that we found out that, yes, they actually were in the wrong.”
She said the whānau received apologies from the hospital and police but “not to the extent that they should have”.
“A lot of it was them saying they were sorry and then saying they did nothing wrong which is contradictory to me.”
She said she was disappointed, disgusted and angry at the people who made the decisions on the day and wished they had done more for her sister.
Unlawful use of restraint and medication
An independent report ordered by Director of Mental Health Dr John Crawshaw found two incidents of restraint and injected medication against the child were unlawful.
Crawshaw released a summary report into the incident after launching an independent inquiry under Section 95 of the Mental Health (Compulsory Assessment and Treatment) Act 1992 to “better understand” and safeguard against any future incidents.
The report found all clinical staff had the wellbeing of who they believed to be the patient in mind but failure to conduct a formal process for confirming the identity of the child was the central failing.
A family member of an 11-year-old has spoken after reports were released into the girl's restraint and forcible treatment. (Source: 1News)
Additionally, it said staff were not aware of existing hospital policies to prevent misidentification, nor did the policies set out clear responsibilities.
It found there was no lawful basis for restraint and medication, and the threshold for urgent treatment was not met – even if staff were treating the woman patient the child was mistaken for.
Crawshaw said he recognised the complexity of the case, the conditions staff were operating under and their good intention, but it was an unacceptable outcome.
"No parent would want their child to be mistaken for someone else, or mistaken for an adult, particularly where that mistake leads to restraint and treatment that should never have occurred.”
He said existing safeguards were not consistently applied in this case leading to the misidentification of the child.
“This failure undermined subsequent decision making and was compounded by staff not being aware of important policies, key decisions not being documented properly, breakdowns in communication between teams, and insufficient medical assessment.”
He said the inquiry focused on systems and practice, rather than on individuals, and he has written to Health NZ seeking a system response.
Child’s rights breached
A separate report by the Health and Disability Commission found Health NZ breached the child’s rights by failing to provide services with reasonable care and skill; that took account of her needs; and in a manner that respected her dignity.
The report by Rose Wall, Deputy Health and Disability Commissioner, said serious mistakes were made and the child’s rights were “severely” compromised.
“She did not receive the quality of care she was entitled to, and services were not provided with reasonable care and skill or in a manner that recognised her specific disability needs,” the report found.
“In addition, her right to dignity was not upheld. It is reasonable to assume that this would not have happened had she not had a disability and been nonverbal in this circumstance.”
Wall noted the expert who advised on the case also said other services would be vulnerable to a similar error. She said Health NZ needed to take leadership and “ensure all districts have appropriate systems and processes in place for supporting disabled people and other at-risk consumers who engage with the health system”.
The commission recommended that Health NZ:
- Apologise to the girl and her whānau for the breaches
- Consider staff development opportunities in the understanding and use of alternative communication tools in emergency departments and mental health settings
- Conduct reviews into cases that used physical restraint or injected medication when there has been a refusal of oral medication in order to form a view on the appropriateness of use
- Provide education in its orientation package to psychiatric staff on admission criteria and procedures for admission to psychiatric intensive care units
- Provide an update on the remaining two recommendations in progress from the rapid incident review
- Give feedback on recommendations within three months.
Health New Zealand-Te Whatu Ora has been referred to the Director of Proceedings to decide whether legal or disciplinary action will take place.
Whānau feedback
The HDC report included whānau feedback revealing they expressed relief the commissioner found “something serious went wrong” and the investigation helped them to learn the “true nature of events” and experience for their child.
It said they were angry police and Health NZ did not provide simple answers to their questions after the event.
The child’s whānau provided statements on the seriousness of the events, the ongoing impact – including on theirs and the child’s mana – the loss of trust and feeling of safety.
The report said the whānau believed the incident and the response from agencies failed to put their child at the centre, and systemic issues needed to be addressed with responsibility and accountability situated at “a higher level” than Waikato hospital.
It was also important for the whānau to disclose their child’s age, ethnicity, and disability so that the incident was captured "fully" and learned from, read the HDC report.
What happened?
At the time of the incident, the 11-year-old girl was known to leave her house and wander for up to several kilometres.
On March 9, 2025, she left her home early in the morning while her mother thought she was in her bedroom. Once it was discovered she was missing, her mother and whānau searched for her but failed to find her.
At 6.40am police received a 111 call from the public who described seeing a woman in her early 20s walking in the middle of the road before climbing up on the rails of Fairfield Bridge in Hamilton.
Two police patrols were dispatched where they located the girl on the bridge.
The Section 95 report said one officer described her as “female, Māori or Pacific Islander, late teens/early 20s very slim build”, and two of the three officers thought she was autistic.
The girl was taken to Waikato Hospital. The Section 95 report said she became increasingly distressed as they approached the ambulance parking area and she attempted to open the car door several times.
She “was unable to give her name to police, and had no identity documents” read the HDC report.
A mental health crisis team of two people met them outside the emergency department.
The Section 95 report again notes that one of the crisis team commented that the girl was “clearly a child and was autistic” and consequently would not take her to the mental health department. A senior staff member from the emergency department agreed and said the girl could remain in ED in the meantime.
The girl was handcuffed while she was escorted from the police car to prevent her from running away.
The HDC report said she was placed in a room with a care partner, and an ED nurse described the girl as appearing to be experiencing hallucinations, was hiding in a corner, and appeared scared.
Misidentification
Back at the police station, one of the officers came across a missing person report for a 20-year-old woman placed under a compulsory treatment order.
The woman had taken leave from a mental health supported accommodation service, provided by a non-governmental organisation, and did not return.
The officer contacted the organisation and sent a photo of the girl for identification.
The Section 95 report stated that the officer said the staff member told them they were confident the photo was of the 20-year-old woman but said they repeatedly told the officer they couldn’t be certain.
The officer contacted the ED senior staff member and relayed the identification details of the woman and, in turn, the staff member referred the matter back to the mental health crisis team.
A different two-member crisis team attended to the girl at the hospital at 9.50am.
The HDC report said the girl was “noted to be burying her head into her pillow and plugging her ears with her fingers”. The crisis team considered her presentation was consistent with that of the 20-year-old woman’s health diagnosis and clinical records from this point referred to the girl by the woman’s first name.
The girl was recalled to hospital for compulsory treatment, and the team transported her to the Henry Rongomau Bennett Centre, where the 20-year-old woman’s medication chart was consulted to treat the girl.
Clinical records showed that the girl continued to show child-like behaviour and distress by curling up into a ball and covering her ears, read the HDC report.
The Section 95 report said the girl did not present any unmanageable behaviour or risk of damage or harm to herself or others.
She refused oral medication despite efforts from multiple staff members. At 12.20pm, staff then restrained her and injected her with anti-psychotic medication. She fell asleep.
At 8.20pm the girl woke and when staff again offered her oral medication, she refused again.
The HDC report said she covered her ears and rolled towards the wall.
The Section 95 report noted, again, that she did not present with unmanageable behaviour or immediate risk of harm to herself or others.
At approximately 8.45pm the girl was restrained and injected a second time.
Discharge from mental health unit
At around 6.20pm, police received a report of a missing 11-year-old girl, and at 9.10pm, one of the officers who picked the girl up saw the report. The Henry Rongomau Bennett Centre was then contacted.
The Section 95 report said a doctor assessed the girl before discharge and her mother was met by a staff member from the centre who explained what happened.
The girl’s mother was given a 24-hour number to contact over any concern and told about potential adverse symptoms. A psychiatrist and four other hospital staff were delegated to make several follow-up home visits.
A rapid incident review was released on April 2.
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