Outrage in New Zealand after 11-year-old girl sent to psychiatric ward and drugged in identity mix-up (My Thoughts)
So far, There have been many reports that have been written on 2 April 2025 of an incident of a young female who was mistaken for her age and identity mix-up.
This young woman was just a young female at the age of 11 non-verbal autistic and was mixed up for a 20 year old. One of the local papers such as The Guardian article reads that An 11-year-old girl was restrained, injected with anti-psychotic drugs and placed on a mental health ward after New Zealand police mistook her for a missing woman, a report found on Wednesday.
What was she doing during this incident happened to her?
Health officials and police have scrambled to explain the mix-up, which has appalled political leaders and stoked outrage across the country. The girl – who displayed “limited verbal ability” – was crossing a bridge in northern Hamilton city when a passing police car mistakenly identified her as a missing 20-year-old female hospital patient, the review said.
Police drove the girl to hospital, where she was admitted to an “intensive psychiatric care unit” despite one nurse suggesting she “resembled a child”. “Patient A lives with a disability that means she was not able to tell people about herself,” said a review by the Ministry of Health, referring to the girl.
After refusing to take drugs offered by staff, the girl was restrained and injected with anti-psychotic medication that is “rarely administered to children”. “Staff were working on the assumption that they were administering medication to an adult, not a child,” read the damning review of the 9 March incident.
Police were called to Fairfield Bridge in Hamilton about 6.40am on March 9, after a person described as a female in her 20s was seen walking in distress.
Acting Waikato district commander Superintendent Scott Gemmell told the Herald the 111 caller reported that the woman appeared to be intoxicated and that city cameras captured her climbing up the rails of the bridge.
Gemmell said police units, including a police boat, responded immediately, fearing her safety.
“She was repeating the questions that the officers had asked her. They weren’t able to form an identification of her at that point, but she looked by virtue of the wider circumstances of someone that needed care and it progressed from there.” The Herald understands the girl is autistic and non-verbal.
How did a child come to be misidentified as an adult?
Superintendent Scott Gemmell, Acting Waikato District Commander has described the events that led to the 11-year-old being misidentified.
Gemmell said police were called about 6.40am on Sunday 9 March to the Fairfield Bridge after a person described as a female in her 20s was seen climbing onto the railings. “Fearing for her safety, police units, including a police boat, responded immediately, and staff attempted to speak to the female. She was unable to give the officers any details and did not have any personal identification on her.”Police were concerned she was suffering from a mental health episode and took her to Waikato Hospital for assessment’s “The female got into a patrol car without requiring assistance or force and was not handcuffed,” Gemmell said.
On arrival at the hospital officers decided to put her in handcuffs when her behaviours caused further concern for her safety, he said. Later speaking to Checkpoint, Gemmell said when the girl was taken to Waikato Hospital, “identification was of primary concern”.
“We took a photo of her and we distributed that amongst our staff on one of our distribution lists. “One of our staff came back with a nomination of a person who was residing in a community based mental health facility approximate to the Fairfield bridge.”
Police then spoke to a carer and sent through a copy of that photograph for identification purposes. “We did that and the carer did come back to say they thought it was this person as well.
“Based on that knowledge, we went into the emergency department at Waikato Hospital, and based on that information that we have to hand, we believed this to be another person.
“We are really disappointed and gutted by what has subsequently happened.”
Gemmell said he had seen photos of the two, and they had similar face, hair and complexion, but officers at the time were relying more heavily on someone who dealt with the 20-year-old more often. Gemmell said the 20-year-old woman was not in a mental health facility at the time of the incident. A local woman was thought to be a possible identity and police sought to confirm this with a mental health service provider who knew that person. Based on that advice they told Waikato Hospital staff, including their rationale for the nominated identity, he said.
“The incorrectly nominated person was not involved in any earlier occurrence and was not being sought by police.” About 6pm that evening, a woman reported her 11-year-old daughter missing, and a staff member recognized her as the female picked up on the bridge. Police staff immediately disseminated information about her, including a photo to all staff, as she was considered a vulnerable missing person due to her age and several other factors.
One staff member recognized her and her family was contacted.
Reported missing
At around 6pm, almost 12 hours after the incident on the bridge, a woman reported that her 11-year-old daughter had gone missing.
“Police staff immediately disseminated information about her, including a photo, to all staff, as she was considered a vulnerable missing person due to her age and several other factors.”
One member of police staff recognized the girl as the one who had been picked up by police earlier that day, and her family was “immediately” notified and given her location. Police took a family member to pick up the 11-year-old.”We know that the events of that morning were likely distressing for the young girl, and her family. We are working with Waikato Hospital to review the events of that day, and better understand how the misidentification occurred,” Gemmell said.
He said officers acted in the “best interests of keeping someone safe”, a person who they believed needed mental health care.
In a statement, Te Whatu Ora deputy chief executive for Te Manawa Taki Cath Cronin said police told health staff she was a missing patient.
“Police advised our staff a short time later that they had identified the young person as a missing patient, subject to Section 29 of the Mental Health Act, and they were admitted to our care. “Police called about 12 hours later to advise they had misidentified the young person. It was not the person they had originally thought. “She acknowledged the distress the incident may have caused and apologized.
“We are very sorry. We have apologized to the young person and their whānau and will remain in contact with them.”
Cronin said a review was being carried out, which would look into any medication or treatment the girl was given.
“We want to fully understand what happened.”Our staff work extremely hard to provide the best care they can for people coming into our care and are deeply disappointed this young person was incorrectly identified.”
Police were concerned she was suffering from a mental health episode and took her to Waikato Hospital’s Henry Bennett Centre for assessment where she was handcuffed and later understood to have been injected with two doses of haloperidol, an antipsychotic medicine. When police arrived at the hospital with the young girl, Gemmell said officers took a picture of her and sought help trying to identify her via a distribution list of police staff.
“One [police staffer] came back thinking that it was another person,” Gemmell said. He said the staffer understood the last known location of the nominated person was in close proximity to the bridge.
“Our staff identified the name of the mental care provider and phoned through … we then asked if we could send a photo through to ask do you think this is the person we’re talking about.”
Gemmell said the carer believed the missing woman in her 20s looked like the young girl, which was then relayed to Waikato Hospital. He said he’d viewed images of the woman and the girl with “critical eyes” and said further corroboration was needed. The pair shared similar hair and similar complexion, Gemmell said: “I saw side profiles that could be similar, but yes … it wouldn’t be enough to give a clear indication.”
About 6pm – some 12 hours after police responded to the bridge incident – a woman reported to police that her 11-year-old daughter was missing.
Health New Zealand has apologized for the “traumatic experience” and said a high-level review would be carried out, which would also draw on independent clinical expertise. Deputy chief executive for Te Manawa Taki (Central North Island region) Cath Cronin said the review would be completed in a matter of days.
“We want to fully understand what happened and will review every step taken while the young person was in our care, including any medication or treatment given, to try to ensure this never happens again.“Our staff work extremely hard to provide the best care they can for people coming into our care and are deeply disappointed this young person was incorrectly identified.”
Asked why the issue wasn’t raised with the Government sooner, police said while they were aware of the misidentification, its ramifications were not apparent until the end of last week.
“It was only then we were made aware of the full picture of events, taking into account information from other agencies,” police said. Gemmell said Waikato Police was also conducting an internal review. Asked what police would do differently next time, Gemmell said: “With the benefit of hindsight, as much corroboration on our identification as we could possibly get is the best way to go forward.
“On this occasion we went with what we thought was a verifiable identification, but it wasn’t and we’ve apologized [to] the mum for the distress that we’ve caused here.”He said bearing in mind police’s thought at that time was her safety, it wouldn’t have been right to take her to a police station and said fingerprinting wouldn’t have brought up a result as such.
He added staff involved in the incident were “really devastated”.
‘Incredibly concerning’: PM Luxton says ministers informed two weeks after incident
Luxton on Tuesday described the incident as “incredibly concerning”.
“As a parent, you identify with what is a horrific set of circumstances that has happened and it’s just incredibly distressing and concerning, massive amounts of empathy and concern for her and her family.”
Ministers were informed of the incident following a Herald query on Friday afternoon, almost two weeks after it occurred.
Luxton said the two-week delay was “unacceptable” and expected the review to uncover what had happened.
Mental Health Minister Matt Doocey was also disappointed it took so long for him to be informed by Health NZ.“I spoke to Dale Bramley, the acting chief executive, to say that was quite frankly not good enough, but the serious incident review is under way and I expect to keep updated on how that review is going.
“It’s every parent’s worst nightmare and that’s why I’ve sought assurance of the welfare of the 11 year old, I’ve been given that assurance that she is doing well.”Doocey said his office wasn’t informed earlier because Health NZ staff didn’t follow its own escalation protocols and the incident “appeared to stay local”, meaning its acting chief executive wasn’t advised either.
“That’s part of the serious incident review now to understand why that wasn’t followed – whether someone actively chose not to escalate the issue, or there was confusion whether some people thought someone else was notifying.”
The girl spent more than 12 hours in hospital until police realised their mistake and called her family to pick her up.
“I just wish to start by apologizing to this young person and her family for the trauma and distress that was caused,” said Richard Sullivan, a senior health official. “This report is a frank read. But it is necessary to make sure this doesn’t happen again. ”The New Zealand prime minister, Christopher Luxton, launched an investigation last week when the incident came to light. “That is incredibly distressing and incredibly concerning,” he said. “As a parent you identify with what is a horrific set of circumstances. I have massive amounts of empathy for her and her family.”
The autistic and non-verbal girl was handcuffed, admitted to Waikato Hospital’s Henry Bennett Centre and medicated, after she was seen climbing a bridge.A five person review panel found police misidentified her, and the hospital accepted that because “it is common for Police to confirm patient identity”.
She was restrained and given two doses of intermuscular medication because she declined oral medication, it said.
The medication used was “rarely administered to children” and not the first line choice for adults – but was given due to a shortage of supply.
Health New Zealand chief clinical officer Dr. Richard Sullivan told media “there are other medications that are more appropriate for children” and as far as he was aware, there were no long-lasting effects. “The medication is used to I guess help calm people and so in this circumstance they would have been calm, they would have been sleepy.”
There was no cultural support offered to the girl, and disability was not considered beyond the initial assessment, the reviewers found. The fact she was not admitted to the Emergency Department, was described as a “lost opportunity for assessment” which could have led to a different diagnosis. The Rapid Incident Review Report said “several failings” contributed to the distress and trauma experienced by the young person and their family.
It was released publicly after the panel spent one week reviewing clinical records and relevant Waikato policies and procedures, interviewing relevant staff, speaking with an external review panel and with the family of the 11-year-old.
Eight recommendations made
The panel made eight recommendations, including an apology to the girl and her family.
It recommended a rapid review of international best practice for the identification of unidentified patients, “particularly for people with any type of communication difficulty”, to create a national policy.
“This should be done in collaboration with cultural and disability services, and in consultation with the police.”
Health New Zealand chief clinical officer Dr. Richard Sullivan.
It recommended that all Emergency Departments undertake medical reviews on all unidentified patients, and that a national restraint group is established “to specifically develop best practice for physical restraint, medication restraint, monitoring after sedation, de-escalation processes and staff training”.
“The scope of this group’s work should include developing a checklist for assessment prior to medication restraint, and procedures for monitoring vital signs following sedation in mental health facilities.”
It recommended that Health NZ reviews its admission criteria and procedures for admission to psychiatric intensive care units, that it reviews workforce resourcing in the district’s mental health inpatient unit, ensures cultural support is offered to mental health patients as early as possible in the admission process.
It recommended that cultural and disability services are engaged “in the actioning of relevant recommendations”.
Those recommendations will be converted into an action plan with clear deliverables and timelines within one week, the report said.
Health NZ’s response
In a statement, Health New Zealand chief clinical officer Dr. Richard Sullivan said staff endeavor to provide high standards of care, and wanted to ensure such an incident did not happen again.
“We recognise this young person and their family’s distress. We are continuing to provide appropriate and on-going support,” he said.
“We accept all of the review the findings. The review team included several senior clinicians from Health NZ, as well as a panel of external experts to Health NZ, who were extensively involved in reviewing and providing feedback.”
Previously, acting Waikato District Commander Superintendent Scott Gemmell told RNZ “identification was of primary concern” when the police took the girl to Waikato Hospital. “We took a photo of her and we distributed that amongst our staff on one of our distribution lists.
“One of our staff came back with a nomination of a person who was residing in a community based mental health facility approximate to the Fairfield bridge.”
Police spoke to a carer and sent through a copy of that photograph for identification purposes, he said. “We did that and the carer did come back to say they thought it was this person as well. “Based on that knowledge, we went into the emergency department at Waikato Hospital, and based on that information that we have to hand, we believed this to be another person.”
Gemmell said the 20-year-old woman was not in a mental health facility at the time of the incident.
About 6pm that evening, a woman reported her 11-year-old daughter missing, and a staff member recognised her as the female picked up on the bridge.
Report’s findings
The report found there was an “assumption” that it was a mental health presentation, as police had told hospital staff the girl was found on a bridge displaying mental health symptoms.
“This resulted in the mental health Crisis Assessment and Home Based Treatment team (CAHT team) being called and asked to assess the patient, without Patient A (the girl) being reviewed by the Emergency Department (ED) medical team first.”
The CAHT team had initially considered the possibility of a different diagnosis and declined the direct admission of the girl into an inpatient unit.
An initial assessment of the girl by the CAHT team and an ED registered nurse found the patient “resembled a child that may have a disability”.
The report said this “demonstrated good clinical judgement and the consideration of a differential diagnosis”.
The misidentification by police was accepted by staff as it was common for police to confirm identity.
“Patient A displayed limited verbal ability, and there was no additional information available to staff to verify the Police’s identification. Patient B also had no next of kin in the system to contact.”
The report said no cultural support was provided to the girl, and the ED medical team did not see her – a missed opportunity for a different diagnosis.
The CAHT team accepted the patient and made a treatment plan based on what would have been appropriate for the 20-year-old woman she was thought to be.
“Current Waikato Hospital identification processes are inadequate for this situation,” the report said.
“From this point, there was a failure to consider any other diagnoses to explain the clinical presentation.”
The girl was medicated in the admission area and transferred into the intensive psychiatric care unit.
She declined to take oral medication, which resulted in health staff administering intermuscular medication (IMI). She was restrained while the staff gave her the drug.
“Staff were working on the assumption that they were administering medication to an adult, not a child,” the report said.
“Medication decisions were based on Patient B’s history of rapid escalation of their symptoms.”
It also said the medication was “rarely” administered to children and was not the first-line choice in adults but was given due to a supply shortage. Two doses of the drug were given to the patient, and no mental health reassessment was completed before it was provided.
Scathing Health NZ review after girl was mistaken for a 20-year-old woman and treated with antipsychotic drugs. (Source: 1News)
The girl’s vital signs were not measured before or after sedation. Visuals of the girl post-medication occurred at “frequent intervals”.
The review said the patient’s care was provided “in the timeframes that would normally be expected.”
It also said: “Several staff commented on high workloads and a frequently full unit”.
It found that once the girl was correctly identified, “appropriate actions were taken”, and the support offered to the family following the ordeal continued.
“The event was immediately reported and recorded as an adverse event, and a review process was commenced. This was consistent with Waikato District’s adverse event process.”
Following the review, Health NZ said it would have an action plan to implement a number of recommendations next week.
The recommendations included
- Apologizing to the girl and her family; undertake a rapid review of international best practices for the identification of unidentified patients.
- Ensuring all emergency departments undertake medical reviews on unidentified patients.
- Establishing a national restraint group for physical restraint, medication restraint, monitoring after sedation, de-escalation processes and staff training.
- A review of admission criteria and procedures for admission to psychiatric intensive care units.
- A review of workforce resourcing in the Waikato District’s mental health inpatient unit.
- Ensuring cultural support is offered to mental health patients as early as possible.
- Engaging cultural and disability services in the actioning of relevant recommendations.
“We also want to make sure Patient A and their family are given appropriate time and support to understand the findings and recommendations, ask questions, and feedback any concerns into the Waikato Serious Adverse Event report process,” Sullivan said.
Recommendations in this situation to learn from
The review panel recommended Health NZ apologize to Patient A and her family, as well as engage with the family and provide appropriate support. The panel has also recommended Health NZ:
- Undertake a rapid review of international best practice for the identification of unidentified patients, particularly for people with any type of communication difficulty, and create a national policy. This should be done in collaboration with cultural and disability services, and in consultation with the Police.
- Ensure all Emergency Departments undertake medical reviews on unidentified patients.
- Establish a national restraint group to specifically develop best practice for physical restraint, medication restraint, monitoring after sedation, de-escalation processes and staff training. The scope of this group’s work should include developing a checklist for assessment prior to medication restraint, and procedures for monitoring vital signs following sedation in mental health facilities.
- Review admission criteria and procedures for admission to psychiatric intensive care units.
- Review workforce resourcing in the Waikato District’s mental health inpatient unit.
- Ensure cultural support is offered to mental health patients as early as possible in the admission process.
- Engage cultural and disability services in the actioning of relevant recommendations.
Police conduct own review
Police also conducted its own internal district review of the day’s events. It found that police’s operational response upon hearing a person was on the bridge was “prompt, with appropriate urgency for securing her safety”. It said the decision to detain the girl was appropriate “given their genuine concerns for Patient A’s safety and wellbeing”.
Police findings released
Waikato police have also released the findings of their internal district review, concluding it was reasonable for officers to detain and place handcuffs on the girl.
The review found police responded promptly and with “appropriate urgency” to the initial call about a female in the middle of the road, and later on the railings of Fairfield Bridge .It found the decision to detain the girl under the Mental Health (Compulsory Assessment and Treatment) Act was appropriate “given their genuine concerns for Patient A’s safety and wellbeing”.
It was “reasonable” for officers to place handcuffs on her at arrival at Waikato Hospital “to protect her own safety and the safety of staff”, the review found.
The police misidentified her despite “genuine attempts to confirm her identity,” it found, and “promptly informed Waikato Hospital of the misidentification” when it became apparent later that day .In a statement, assistant commissioner Sandra Venables said there was a broader review underway, which was still in the information-gathering phase. “We acknowledge that the events have been distressing for Patient A and their family. Waikato police have met with the family and apologized for the misidentification,” she said.
“What we know at this stage is that the misidentification occurred despite the genuine efforts of our staff to identify the female. However, we also know that our processes can be improved to further reduce the risk of an incident like this recurring.”
The incident has also been referred to the IPCA.
Health NZ has apologized after an 11-year-old girl was mistaken for a 20-year-old woman and admitted to a mental health facility.
The girl was handcuffed by police officers after they misidentified her and took her to Waikato Hospital’s Henry Bennett Centre.
The New Zealand Herald reported the girl was autistic and non-verbal, and injected with medication at the hospital. Te Whatu Ora said a review would be carried out to see if any medication had been given to the girl.
Te Whatu Ora deputy chief executive for Te Manawa Taki Cath Cronin said the girl was taken to Waikato Hospital’s emergency department by police who told staff she was a missing patient.
“Police advised our staff a short time later that they had identified the young person as a missing patient, subject to Section 29 of the Mental Health Act, and they were admitted to our care.
“Police called about 12 hours later to advise they had misidentified the young person. It was not the person they had originally thought.”
Health NZ apologizes after 11-year-old mistaken for 20-year-old and admitted to mental health facility
Police then advised that they believed the girl to be a missing young person.
Her family arrived to take her home.
Cronin acknowledged it was a distressing and traumatic experience.
“We are very sorry. We have apologized to the young person and their whānau and will remain in contact with them,” she said.
A review was being carried out, including into any medication or treatment given to the girl, Cronin said.
“We want to fully understand what happened.”
In a statement, Waikato police said the girl was not initially handcuffed when officers were taking her to hospital but, but once there they put handcuffs on her.
Superintendent Scott Gemmell, Acting Waikato District Commander, said police were called about 6.40am on Sunday 9 March to the Fairfield Bridge, Fairfield, after a person described as a female in her 20s was seen climbing onto the railings.
“Fearing for her safety, police units, including a police boat, responded immediately, and staff attempted to speak to the female. She was unable to give the officers any details and did not have any personal identification on her.”
Police were concerned she was suffering from a mental health episode and took her to Waikato Hospital for assessment.
“The female got into a patrol car without requiring assistance or force and was not handcuffed,” Gemmell said.
On arrival at the hospital officers decided to put her in handcuffs when her behaviours caused further concern for her safety, he said.
Speaking to Checkpoint, Gemmell said when the girl was taken to Waikato Hospital, “identification was of primary concern”.
“We took a photo of her and we distributed that amongst our staff on one of our distribution lists.
“One of our staff came back with a nomination of a person who was residing in a community based mental health facility approximate to the Fairfield bridge.”
Police then spoke to a carer and sent through a copy of that photograph for identification purposes
“We did that and the carer did come back to say they thought it was this person as well.
“Based on that knowledge, we went into the emergency department at Waikato Hospital, and based on that information that we have to hand, we believed this to be another person.
“We are really disappointed and gutted by what has subsequently happened.”
Gemmell said he had seen photos of the two, and they had similar face, hair and complexion, but officers at the time were relying more heavily on someone who dealt with the 20-year-old more often.
Gemmell said the 20-year-old woman was not in a mental health facility at the time of the incident.
A local woman was thought to be a possible identity and police sought to confirm this with a mental health service provider who knew that person. Based on that advice they told Waikato Hospital staff, including their rationale for the nominated identity, he said.
“The incorrectly nominated person was not involved in any earlier occurrence and was not being sought by police.”
About 6pm that evening, a woman reported her 11-year-old daughter missing, and a staff member recognized her as the female picked up on the bridge.
Police staff immediately disseminated information about her, including a photo to all staff, as she was considered a vulnerable missing person due to her age and several other factors.
One staff member recognized her and her family was contacted.
“We know that the events of that morning were likely distressing for the young girl, and her family. We are working with Waikato Hospital to review the events of that day, and better understand how the misidentification occurred.
“Our staff acted in the best interests of keeping someone safe; a person they believed needed mental health care.”
Mental Health Minister Matt Doocey said he expected to be kept fully informed of the condition of the 11-year-old, and the 20-year-old she was mistaken for.
“This is an incredibly distressing set of circumstances. What occurred is not acceptable and my heart goes out to the two young people involved and their families,” he said.
“I understand Health New Zealand has launched an investigation into this incident, and both myself and the Minister of Health expect to be kept fully informed of the outcomes.”
Autism New Zealand chief executive Dane Dougan told Morning Report it came down to a lack of understanding of autism.
“If we focus in on the autistic part, and obviously being non-communicative at that particular time, it was clearly a relatively significant misunderstanding that caused a pretty traumatic event for the young lady,” he said. “This all sort of stems down to, I think, at the end of the day, a lack of understanding of autism and how autistic people try to communicate at times.
Dougan said it was hard to fathom how an 11-year-old autistic girl could be mistaken for a 20-year-old woman. He called for there to be more training for first responders around understanding people with autism.
“It just puts everyone in a safer situation if there’s a better understanding of autism. “If we are a first responder and seeing someone acting in this way, having an understanding that they may be autistic could really help avoid these situations in the future, and I think that does come down to education and training.”
Final Thoughts:
Every child does deserves love, compassion, individualized care and more that will respect their humanity and neurodiversity. Systemic reforms are often needed to prevent such incidents like this one mentioned. There need to be some interventions such as better training for healthcare providers as well as also law enforcements, and stronger safeguards for non-verbal individuals. If this is an ongoing matter, prioritizing the child’s safety and rights through formal channels is essential.