VICTORIA - The British Columbia government failed to meet the legal rights of mentally ill patients who were involuntarily detained in psychiatric facilities during a one-month review, sometimes without admission forms being completed, a new report says.

Jay Chalke, the province's ombudsperson, said Thursday he was "taken aback" by the findings from an investigation into whether legal documentation was being obtained to ensure proper procedures are followed under the Mental Health Act when people are detained against their will if they are considered at risk of harming themselves or others.

"When we conducted our investigation what we found was alarming," Chalke said, adding all required forms were filled out for only 28 per cent of admissions, and one facility, the University Hospital of Northern British Columbia, complied with that procedure in obtaining consent for treatment only nine per cent of the time.

The investigation examined 1,500 admissions in June 2017, with some people being admitted more than once, and for an average of 14 days, he said.

In some cases, doctors did not explain why a patient was being admitted and in 24 per cent of admissions, no consent form was obtained, Chalke said, adding more than half of involuntary patients did not sign a form advising them of their legal rights including how to challenge their detention.

"In other cases, a standard rubber stamp was used covering any possible treatment in boilerplate language rather than specifically identifying a particular treatment for that individual."

Chalke said proper procedure must be followed because 15,000 involuntary admissions were recorded in B.C. in 2016-17, an increase of 70 per cent in a decade.

Laura Johnston, a lawyer with the Community Legal Assistance Society, said the report reflects what the group has said for years about the need to comply with the Mental Health Act in a system that is "operating in darkness."

"We're concerned that there's no oversight or monitoring of the mental health system," she said.

Johnston said she met with government officials after the society released its own report in 2017 but there's still no commitment to change a law that allows patients to be put in mechanical restraints and solitary confinement without limits or review.

"Those of us who work in community with involuntarily detained patients have been saying for years that we see compliance problems," she said.

"A lot of our clients report that their experience has been so terrifying that they delay seeking mental health services or avoid seeking mental health services in the future because they're so frightened."

Chalke's report calls for regular audits, annual performance targets, improved records management and increased reporting to the public, as well as training for staff and physicians to meet legal standards.

He also recommended that an independent rights service be established through legal aid funds, and the Attorney General's Ministry has agreed to do so.

Mental Health and Addictions Minister Judy Darcy said her ministry, the Health Ministry and health authorities are moving ahead to fulfil the 24 recommendations in Chalke's report and that training programs are being developed for doctors and health-care providers.

She said a training video is also in the works for patients and their families so they can understand their rights and involuntary admissions under the act.

"Our goal as a government is to keep people safe," she said. "That means always balancing the rights of the individuals with the need to ensure people with severe mental health issues are not a danger to themselves or others and we're working to get that balance right."