My recent call for a Senedd debate in Welsh Government time on the Holden Report, published last month, documenting failings on the Hergest Mental Health Unit in Bangor, was rejected.
We have therefore brought forward this opposition debate on a matter which has had longstanding Welsh Government involvement.
In 2012, the Deputy Coroner wrote to the Health Board outlining her concern after a women had died in the Hergest Unit.
After Professor David Healy, from the Department of Psychiatry in the Hergest Unit, raised concerns over developments in the provision of Mental Health Services in North Wales, Lesley Griffiths, then Health Minister replied to Darren Millar in 2012 stating “an independent review would commence shortly”.
After I raised the same concerns with the then Health Board’s Chief Executive, she replied to me in 2012 that she had “initiated an investigation”.
The Board was not put into special measures until June 2015 after an external investigation revealed that patients had suffered institutional abuse in Glan Clwyd Hospital’s Ablett Acute Mental Health Unit.
The Health Board stated that it was alerted to serious concerns regarding patient care on the Tawel Fan Ward in the Ablett Unit in December 2013 – but concerns about this Ward went back a lot further.
For example, in 2009, I raised with the Welsh Government and Health Board the concerns of a constituent who said that the treatment received by her husband in the Ablett Unit “nearly killed him”, that three other patients admitted around the same time as her husband had similar experiences and that she was now worried about the treatment others may receive in this Unit.
Ahead of the Holden Report’s publication I was one of five Members to receive correspondence from a retired NHS executive, after he had seen the report and appendix.
He stated:
“Up until now the Health Board has protested that the main text of the Holden Report and its Appendix, completed in December 2013 and containing extracts from the damning statements of 40 whistle blowers, must remain hidden from public view in order to safeguard the confidentiality of the whistle blowers. The decision to withhold evidence of neglect on such spurious grounds was deliberate and wilful.
“The Health Board has finally given up this pretence by now accepting the Information Commissioner's ruling, first made over 16 months ago, that the report should be published in full.
“It is now crystal clear that the main body of evidence provided by the whistle blowers - all of them key members of staff on the Hergest Unit - was deliberately kept hidden from view. This was done not to protect the identity of the whistleblowers but to conceal the acts and omissions of their senior managers that were causing staff to be bullied and patients to be neglected.
“The Health Board made a brief summary of the report available to the Public Accounts Committee in November 2015. Publication of the full report now reveals just how much detail was concealed from the Public Accounts Committee at that time”.
As he asked:
“how then was it possible that in 2014 the most senior of these managers was allowed to make reports to the Health Board and its Quality Committee which concealed his own part in the Holden process?’
And ‘has the Health Board now satisfied itself that the senior officials responsible for this mess, and for keeping it under wraps for so long, have now all been removed from any responsibility for the care of vulnerable mental health patients?
Speaking here in September, the Health Minister said it was important to note that a summary report was published in 2015, including the Holden recommendations, but this is the very brief Summary Report referred to above, which did not describe the 31 concerns listed by staff.
Throughout my time as a Member of the Senedd since 2003, I have supported a succession of principle Whistleblowers who had been threatened, bullied, denigrated and damaged for daring to tell the truth in Wales.
An event that led directly to Holden involved two senior nursing staff, who had raised safety concerns, being summarily marched out of the building on a trumped up basis.
In the case of Tawel Fan, two members of the medical staff were put on restricted duties and referred to the GMC .
One of them had raised safety concerns with management but was told that doing so indicated he was not a team-player.
A letter I received from Professor Healy, in 2019, stated:
“Several of my patients have died, in part because of difficulties in getting them input. I wrote to the Health Board about one patient, now dead, who was getting more care co-ordination from the N Wales police than from the mental health services, but I do not get even acknowledgement of receipt of letters.”
False allegations were made against him. He was exonerated each time and finally accepted a job offer in Canada.
However, a letter received from him this week states:
“A merger of health boards across North Wales put Wrexham based staff in charge of the entire service.
“Bullying, thuggery, summary dismissals based on trumped up charges, invented sexual abuse allegations became par for the course. Staff who raised safety concerns were told they were not team players and were dismissed.”
“Some politicians at least acknowledged the receipt of letters from senior staff drawing their attention to these issues. Mr. Drakeford never did … his recent comments on what happened have been jaw-droppingly wrong”.
Responding here to the 2018 statement by the then Health Secretary, Vaughan Gething, on the HASCAS Report on the Tawel Fan Ward, I stated:
“in 2015, Welsh Government, the Health Board and Healthcare Inspectorate Wales all accepted the findings of Donna Ockenden's 2015 report. So, why now, when many serious allegations are peppered throughout the HASCAS report, has it come to the bizarre conclusion that care was good and that institutional abuse didn't happen?”.
The 2018 Ockenden Review “found that the systems, structures and processes of governance, management and leadership introduced by the BCUHB Board from 2009 were wholly inappropriate and significantly flawed”.
In January 2019 Donna Ockenden revealed that staff had told her services ‘were going backwards’.
Last month, a Public Services Ombudsman for Wales report also revealed that the Health Board had made a fulsome apology to the son of a lady who received treatment on the Hergest Ward—David Graves – ‘for the failings identified and injustice’ caused to him and his family.
In a letter sent to the Older People’s Commissioner for Wales, the Health Board’s Executive Director of Nursing and Midwifery stated “Mr Graves has at times been verbally aggressive and made expressions which have forced the Health Board to consider the safety of the individual”.
In response, Donna Ockenden wrote “I have always found you polite and courteous”.
Yesterday, North Wales Community Health Council’s Chief Officer wrote to me ahead of this debate stating “When it comes to implementing recommendations of challenging reports BCUHB have been slow to act – some might say reluctant”.
Our motion therefore calls on the Welsh Government to apologise to staff, patients and the families of those adversely affected and to undertake a fundamental review of mental health services across Wales with patients, families, professionals and other stakeholders.