‘Mental health patients dying due to culture of cover-ups at health board’
Politicians demand full Publication of 2013 rePort into mental health services which has ‘yet to see light of day’
PEOPLE with mental health problems are still dying in North Wales because of a “cover-up culture” within the region’s health board, it has been claimed.
Over the past three years there have been 25 cases of patients coming to harm, according to Llyr Gruffydd, Plaid Cymru’s North Wales MS.
Late last year a man died at the Ablett Unit at Ysbyty Glan Clwyd, Bodelwyddan, and in April this year a woman from Caernarfon took her life at the Hergest Unit at Ysbyty Gwynedd, Bangor.
“She was able to do so because the same ligature risks that were present a decade ago, had not been eliminated,” he told a Senedd debate on mental health services in North Wales.
Mr Gruffydd claimed problems remain because Betsi Cadwaladr University Health Board is “refusing” to release a 2013 report commissioned after staff raised concerns over patient safety.
The Holden Report was based on 45 staff interviews and 700 pages of witness statements – but only a summary has ever been published.
Last year, the Information Commissioner ordered full publication of the report – but it has “yet to see the light of day”, said Mr Gruffydd.
“I fear we are seeing a culture of cover-up and a refusal to accept responsibility at the very highest level of both government and health board,” he said.
“To my knowledge, not one manager has been directly disciplined, although last week it was revealed that two managers were moved from their posts.”
Health Minister Eluned Morgan said releasing the full report was a matter for Betsi but as there is an ongoing case involving the Information Commissioner, she said it was “not appropriate” to comment further at this stage.
Having read the report herself, she accepted its contents make “uncomfortable reading”.
The minister said significant improvements were being made by Betsi – but she was keen to “increase the pace of change”.
“What I can say is that I expect the health board to fulfil its statutory obligations to both the people of North Wales, in terms of openness and transparency, but also to its staff by protecting the anonymity of people who raised concerns,” she said.
The Holden Report concluded mental health patients in North Wales were not getting the treatment they needed and deserved.
Vulnerable elderly patients were said to have been placed next to drug addicts, while staff were unable to report problems because of time constraints.
One patient was said to have died while no doctor was available because of rota gaps.
Moreover, said Mr Gruffydd people died because of ligature risks that “should not have been there”.
“It was a recipe for disaster,” he told the Senedd.
“This is a tragic, avoidable scandal. It’s a scandal because nobody has been held to account for the failings.
“These are the longterm failings of senior managers who have continued to be employed by Betsi.
“It was avoidable because staff, families and Holden had raised the alarm many years earlier. The tragedy is that action was not taken. And that means vulnerable people are still dying on mental health units.”
Six years ago the health board was taken into special measures by Mark Drakeford, the then-health minister. Concern over mental health services was cited as a reason.
Last November the special measures were removed and instead Betsi was placed into targeted intervention.
According to Ynys MÔn MS Rhun ap Iorwerth, Plaid’s health spokesperson, ongoing questions about patient safety at the Hergest unit suggested Betsi had been taken out of special measures prematurely.
He said Betsi was still facing “very grave problems” with “deep-rooted issues” over patient welfare.
Mr ap Iorwerth was joined by a succession of North Wales politicians demanding full publication of the Holden report.
Mark Isherwood, who first raised the issue a decade ago, said Betsi’s problems “cannot be dismissed as ancient history”, especially as two patients had died in the past year from “hanging and attempted hanging”.
He said the Information Commission had asked for the report to be published with only the names of the 42 whistleblowers redacted.
But the North Wales Adult Safeguarding Board had blocked the request due to “an absence of specific detail”, he told the Senedd.
Mr Isherwood added:
“The onus is now on the Welsh Government to ensure transparency and to show that it is not complicit in a coverup.”
Dwyfor Meirionnydd MS Mabon ap Gwynfor, founder of the North Wales Health Alliance, said “someone has to take responsibility for these terrible failures” if confidence is to be restored in Betsi’s mental health services.
Clwyd West MS Darren Millar added: “How many more people have to die? How many more vulnerable people need to suffer harm unnecessarily? How many more families need to lose their loved ones before we will see the radical action that is necessary to resolve the fundamental problems that we still have in our mental health services in North Wales?”
Ms Morgan acknowledged the “recent and tragic” incidents at Betsi which, she said, have been reported to NHS Wales and are being investigated.
The week before last a “frank and open” multi-agency round table discussion was held to ensure the right mechanisms were now in place at Betsi.
The Holden recommendations have been acted upon by senior Betsi managers and, while in special measures, the health board made improvements to the governance, management and provision of mental health services, said the minister.
A new chief executive has been appointed and there is much greater oversight, she said. Ms Morgan said the Welsh Government is continuing to monitor and support the health board. Acknowledging the impact of so much scrutiny on staff morale, she saluted the efforts of Betsi’s health staff and the commitment of the health board to improve its mental health services.
But she added: “I am clear there is still a long way to go and that’s why the health board remains in targeted intervention. The board has also been very realistic and in its own assessment recognises there is much work to do.”
It’s a scandal because nobody has been held to account for the failings
MSs Llyr Gruffydd (top) and Rhun ap Iorwerth have spoken out on the region’s mental health ‘scandal’