All Recommendations Accepted in Mental Health Inquiry
All the recommendations have been accepted from an external review into the treatment and management of a forensic
mental health patient Manjit Singh by Auckland’s Mason Clinic.
The external inquiry, reported to the Director of Mental Health, into the management and treatment of community-based
Mason Clinic special patient Manjit Singh found existing legal restrictions on special patients were appropriate, but
made recommendations on improving their local application.
A summary of the Inquiry and its full recommendations have been released - other parts of the Inquiry related to the
detailed clinical treatment of Mr Singh, have been assessed as not meeting the test for being in the public interest and
have not been made publicly available.
In particular, the report has recommended that automatic six monthly reviews of special patients should only be changed
to 12 months in cases where the patient was deemed to be sufficiently stable and unlikely to change in this respect in
the near future.
The Ministry has also met another recommendation by clarifying the advice to mental health services about the management
of special patients on weekly leave.
Services have reported that some of the conditions that allow special patients to be recalled from leave are thought to
interfere significantly with social arrangements in place for special patients, and may act as a disincentive for
services to act decisively in recalling special patients from leave.
Director of Mental Health Dr John Crawshaw says the Ministry will reiterate that services can recall special patients on
leave for short periods, and as long as the patients are stable, taking their medication and meeting other conditions,
then they can be again placed on leave.
The Ministry acknowledges that the report found that the processes followed by the Mason Clinic in making decisions
around the care of Mr Singh were largely found to be sound.
The review stated that overall the standard of clinical care was of a very high standard.
Dr Crawshaw says all those involved in the incident are highly motivated to look carefully at what happened and build
any learnings from the incident into regular service protocols and procedures.
This will now be the focus of the local service and the Ministry will be assisting to ensure that other mental health
services also have a good opportunity to learn from what happened.
The Inquiry was carried out by Dr Nick Judson and David Niven. Dr Judson is a Wellington based consultant in forensic
psychiatry. David Niven is an Auckland based District Inspector.
Mr Singh was a special patient under the Mental Health Act after being found not guilty by reason of insanity of serious
charges relating to a 2008 attack on his partner, when he breached the conditions of his leave, and again attacked his
former partner in November last year.
Mr Singh was on leave from the Auckland-based Mason Clinic when the attack happened.
Leave is allowed for some special patients, as part of their treatment and rehabilitation to help prepare patients for
their eventual return to society.
The Director of Mental Health approves the stages of this short term leave on the basis of recommendations of the local
In July 2016 Mr Singh was sentenced to jail for seven years and to be detained in hospital as a special patient under
the Mental Health Act while he is mentally unwell. The time spent in a secure mental health service counts towards his