Ministry of Health director of mental health, Dr John Crawshaw says a newly released report describes an "unhappy chapter" in mental health services in the Hutt Valley.
Ministry staff on Thursday released a long-awaited report highly critical of services run by the Hutt Valley District Health Board from 2008 to 2010, and Dr Crawshaw decribed it as a "good report".
Dr Crashaw says there was never any intention to keep the critical findings secret.
Release of the findings followed applications by Radio New Zealand under the Official Information Act.
Ministry officials say it received the report in February, but time was needed for Dr Crawshaw, to consider it and respond, and Dr Crawshaw says there was no intention to suppress the findings.
Services were disorganised, under-staffed, marked by relationship breakdowns and may have breached the Mental Health Act, the report says .
The inquiry, ordered by the Director of Mental Health in 2010, probed high-profile concerns about treatment blunders.
It contains disturbing details, including staff of the Te Whare Ahuru inpatient unit failing to record an incident in early 2010 where a patient set fire to herself.
All personal details, such as patient names, have been removed from the report, but it reveals wide-ranging problems, with individual patient care and with management, including under-staffing, poor relationships, and a lack of understanding by clinicians of their duties under the Mental Health Act.
Functioning of the office of the Director of Area Mental Health was disorganised, there was a breakdown with district mental health inspectors, and there were staff shortages.
Problems were compounded by the Hutt Valley District Health Board management pushing ahead with restructuring in a way which contributed towards the destabilisation of mental health services.
DHB chief executive Graham Dyer says the board accepts that assessment.
Mr Dyer says the mental health services are now fully staffed and functioning well,and there shouldn't be a witchhunt over the failings.
There's no need for heads to roll, says Mr Dyer.
The Section 95 inquiry was carried out by barrister and Auckland and Northland District Inspector for Mental Health Barry Wilson, Dr Clive Bensemann of the Auckland District Health Board and Heather Casey, nursing director at the Southern DHB.