In 2024, the woman was placed under a six-month compulsory treatment order and discharged to a supported accommodation service. She later went on leave and didn’t return to the service or engage further with mental health services.
The report, released this morning, detailed the incident, which began early on March 9 when Hamilton police received a 111 call about a person seen walking in the middle of the road just before the Fairfield Bridge, which spans the Waikato River, and then climbing on the rails of the bridge.
The description included that the person was a woman in her early 20s.
The girl was the subject of the 111 call but could not be identified by police, who later handcuffed her as she became “increasingly distressed”. The inquiry deemed that action was warranted, given police concerns about her fleeing or self-harming.
Officers who responded to the callout floated the idea that the girl could be “Person B”, but that suggestion was seemingly dismissed.
“[Officers] noted similarities, but none of them thought they were the same person,” the report said.
Police contacted the woman’s accommodation service and emailed a photo of the girl. The report stated the officer had said the service staffer told them they were “confident” the girl in the photo was in fact “Person B”.
However, the staffer told the inquiry they “repeatedly told [the officer] they couldn’t be certain they were the same person”.
This then led to the officer informing hospital staff treating the girl that there had been a “potential identification” and provided the woman’s details, which then prompted the girl to be detained at Waikato Hospital because of the woman’s medical history.
The inquiry described the police actions as a “significant contributing factor” in misidentifying the girl because the officer didn’t convey the doubts of fellow officers about her identity.
“Police Officer 1 thereby gave an unbalanced impression of the reliability of this nomination and, further, did not provide any details that would have allowed hospital staff to conduct any independent checks.”
The girl was then given “intramuscular medication under restraint” without her consent, which was deemed in line with Person B’s medical history.
However, the inquiry found the injections were administered “without lawful authority”, because they’d been given more than a month after the compulsory treatment order was made and without a second opinion as required under the Mental Health Act.
It wasn’t until after the injections that the girl was correctly identified and reunited with her mother.
The girl’s mother told the inquiry her daughter hadn’t said anything about the incident, but there had been “clear behavioural changes”.
“Person A’s mother also said that she personally found it difficult to process details of the incident as it unfolded, but that over time, both she and her other children experienced a wide range of emotions about the incident.”
The mother told the inquiry: “This has had an enduring and detrimental effect on me and on all my kids.
“Most of all, it has made [Person A] feel unsafe in her daily life when we have worked so hard to help her to be okay in a world not designed for her.”
The inquiry, released alongside reviews from the Health and Disability Commissioner and Health NZ, made several recommendations, including:
Updating national patient identification policies to account for “process gaps” identifiedReview guidelines for sharing information between police and hospital staff at a national levelReview the underlying legal reasoning for existing practice regarding detention in hospitalUpdate policy documents and guidelines to clarify expectations for medical assessments on admission and for charting and administering medicationIntroduce in-service training modules to increase awareness of autism and possibly other neurodiverse conditions
Ministry of Health mental health director Dr John Crawshaw, who apologised to the girl and her family, said Health NZ had developed an action plan to address the recommendations and had “committed to monitoring and reporting on progress”.
Adam Pearse is the deputy political editor and part of the NZ Herald’s press gallery team based at Parliament in Wellington. He has worked for NZME since 2018, reporting for the Northern Advocate in Whangārei and the Herald in Auckland.