‘There’s a limit to how often health board can be allowed to mark own homework’
WATCHDOG DEMANDS EMERGENCY MEETING AFTER CRITICAL REPORT ON PATIENT DEATHS
AHEALTH watchdog is to call for an extraordinary general meeting of the North Wales health board following a critical report into the deaths of two patients in its care.
The report, contained amongst more than 450 committee pages, highlights further failings in mental health services in the region.
Its publication came less than a fortnight after health minister Eluned Morgan warned Betsi Cadwaladr University Health Board it needed to make significant improvements or it could be placed back in special measures.
The new report has since been withdrawn, pending inquests into two patients who died in North Wales hospitals in 2021.
It noted failings in the care of a 47-year-old woman who, in April, took her own life at Ysbyty Gwynedd’s Hergest Unit, Bangor, where she had been placed in a ward with older, more frail patients, a practice known as cohorting.
Observations were not carried out often enough, leading to “catastrophic” outcomes, said the report.
Six months later, in October, a 24-year-old man died in the Ty Llewelyn medium secure unit at Ysbyty Bryn y Neuadd, Llanfairfechan, Conwy.
He had complained of abdominal pains but, despite a “strong aroma” coming from his room, staff failed to recognise the signs of his physical deterioration. He was left unchecked for 11 hours, said the report.
The criticism is the latest in a series of damning inquiries into Betsi Cadwaladr’s mental health services stretching back almost a decade.
Following a perceived “lack of progress” dating back to the 2013 Holden report, which found a culture of staff bullying at the Hergest Unit, in January
the North Wales Community Health Council (NWCHC) called for an independent external review mental health services across North Wales.
In the wake of the latest revelations, it is now demanding the health board convenes an Emergency General Meeting to explore urgent solutions.
NWCHC will also be inviting Eluned Morgan along – and is vowing to “empty chair” her if she declines.
NWCHC chief officer Geoff Ryall-harvey said: “We were led to believe the toxic mix of cohorting was a thing of the past.
“The health board has been given plenty of opportunities to improve the situation but there is a limit to how often it can be allowed to mark its own homework.
“It is impossible to overstate the level of serious concern we have about the provision of mental health services in North Wales.”
The health board was placed in special measures for five years and there were removed just months before the deaths of the two patients last year.
Darren Millar, Welsh Conservative shadow minister for North Wales, called for an “urgent and rapid plan of action” from the Welsh Government to resolve the region’s problems in mental health care.
He said: “These reports make for extremely distressing reading and my heart goes out to the loved ones of those who died as a result of yet more failings in the NHS in North Wales.”
Last month an explosive report by the Royal College of Surgeons (RCS) made five urgent recommendations “to address patient safety risks”.
It highlighted shortcomings in the region’s vascular services after they were centralised to Ysbyty Glan Clwyd in April 2019.
The findings included a case of an unnecessary amputation and an amputee’s wife having to “carry him to the toilet” after he was sent home without a care plan.
Health Minister Eluned Morgan told Betsi Cadwaladr it needed to make significant improvements in the next three months or there would be “consequences”.
But Mr Ryall-harvey said: “We’ve been here before – how many last chances does the health board need?”
Teresa Owen, executive director of public health and BCUHB’S mental health and learning disabilities division, apologised to the loved ones of the two patients who died last year.
She said: “These are two very tragic cases and our hearts go out to the families of both patients.
“We are determined to leave no stone unturned in order to learn lessons from these tragic incidents.
“That is why we commissioned these external reports, which we have made public in line with our commitment to openness and transparency.
“We are determined to deliver further improvements, at pace, over the coming weeks and months.”
The Welsh Government said it wanted to see evidence of these promised improvements.
A spokesperson said: “Our sympathy is with all those affected by these two tragic deaths.
“Betsi Cadwaladr University Health Board has accepted the recommendations in these reports and we expect them to be implemented as soon as possible.”