A review of mental health care in Christchurch, sparked by three deaths, has recommended increasing the number of acute inpatient beds.
Canterbury District Health Board commissioned the review in March after three inpatients at Hillmorton Hospital died within weeks of each other.
The external review heard of units with too many patients, hurried discharge planning and delayed needs assessments.
One of its main recommendations is the reconfiguration of beds, which would result in more available in the hospital's acute inpatient service and fewer in its rehabilitation area.
The board's chief psychiatrist, Associate Professor Phil Brinded says the hospital operates under a very high pressure working environment with high occupancy rates.
He says the Canterbury District Health Board is not the only one which has the problem of over-occupancy.
Dr Brinded says mental health providers have been swimming against a tide in the last decade of decreasing inpatient beds, in favour of an increase in community care.
"I think its a very good question to ask as to whether its good enough for patients and good enough for staff to put up with units at up to 95% to 100% occupancy all of the time."
Former mental health commissioner, Mary O'Hagan, says Hillmorton Hospital is already among the country's more institutionalised services. She says overcrowding is best solved by providing care alternatives.