The Ministry of Health has such "abysmal" record keeping it was unaware intellectually disabled people in its care had died, according to The Chief Ombudsman.
Around 6000 New Zealanders with intellectual disabilities are in residential care paid for by the Ministry of Health.
A review undertaken by Peter Boshier's office has revealed "significant gaps" in the collection of information which he says are unacceptable.
"We looked at two and a half years [of deaths]. There were 108 deaths of people with intellectual disabilities and in a lot of those cases the record keeping was so deficient we didn't know what had happened," Boshier said on Friday.
"In 30 of the deaths alone the Ministry section responsible for looking after these people didn't even know they had died."
He says the investigation began after the Ombudsman was approached in 2018 by mental health and disability professionals concerned about people dying in unclear circumstances.
"We needed to shine a light on the welfare of people who have intellectual disabilities who are often well below the radar in New Zealand."
Since the report began, a series of changes have been implemented - one of which has been brought in by Director General of Health Dr Ashley Bloomfield.
"It was decided after our investigation there would be a special unit set up in the Ministry to address some of the very issues that we had begun looking at," said Boshier.
As a part of the Ombudsman's recommendations Boshier said there needs to be clarity and certainty around the deaths of people in residential care.
"When there is a death [it's recommended] we capture what has happened, and why and how it could be avoided in the future. We have recommended it all be recorded and typed up so this kind of thing can be prevented."
In a statement on Thursday, Boshier said the Ministry has already taken steps to improve it's process - but more needs to be done.
"The Ministry has acknowledged the need for further improvement, and stated its commitment to implementing my recommendations. I will monitor progress closely, and am encouraged by the way in which the Ministry has engaged with my investigation."
