A patient who set herself on fire while in the care of Hutt Valley mental health services was let down by staff shortages, an inquiry has found.
The critical report into the state of Hutt Valley District Health Board's mental health services over a two-year period found it was disorganised, incidents went unreported, there were treatment errors, it lacked leadership and breached the Mental Health Act.
The report, ordered by the the Director of Mental Health in June 2010 after inspectors raised concerns about the service, looked at a period between June 1 2008 and May 31 2010.
It investigated the treatment of five patients, including that of a woman who set herself on fire while being treated in the acute inpatient unit.
The incident was not recorded by the under-staffed unit and the Director of Mental Health was only notified of it three months after it took place.
The inquiry found the office of the director of Area Mental Health was disorganised as he juggled a number of roles while trying to implement a new strategic plan.
During the period under review, the report said the service failed to comply with the Mental Health Act.
Consents or second opinions were not completed, patients not covered by the Act were being treated under compulsion and some patients were discharged without any paperwork being completed.
It said issues with the service were compounded by a restructure.
The Health Ministry's mental health director Dr John Crawshaw the period covered an "unhappy chapter" in mental health services in the Hutt Valley.
"I extend my sympathy to those individuals and their families involved in the inquiry and the two years it covers."
He said the investigation has led to changes and among its recommendations was that there was adequate staffing of the inpatient unit.
Hutt Valley DHB chief executive Graham Dyer says most of the recommendations in the report had been addressed or were in the process of being implemented.