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Vaughan Gething, Minister for Health and Social Services

First published:
29 January 2019
Last updated:

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An independent review of actions taken by Abertawe Bro Morgannwg University Health Board (UHB) between 2011 and 2013 in relation to the Kris Wade case is today published by Healthcare Inspectorate Wales (HIW).

Between 2011 and 2013, three female patients made allegations of sexual abuse against Kris Wade, who was employed by the health board.

He was subsequently arrested and convicted of murder in 2016. At the time of his arrest, he was still an employee of the health board but not working with patients due to his suspension. He had been suspended from work since 2012 pending the outcome of the health board’s disciplinary investigation following the abuse allegations.

Following his conviction, the health board carried out an internal review of the events to look at how it handled the allegations made by its patients and the subsequent disciplinary process. The health board’s review found shortcomings in its processes and established an action plan for improvement.

I asked HIW to carry out this special review to be assured that appropriate actions had been identified by Abertawe Bro Morgannwg UHB and that effective arrangements had subsequently been put in place across the organisation to monitor the implementation of any changes in policies and procedures. 

HIW has identified the following weaknesses:

  • Quality and safety governance arrangements
  • Adult safeguarding
  • Incident reporting
  • Staff recruitment and employment 

The issues regarding quality and safety governance arrangements are particularly disappointing as similar issues were highlighted in the Trusted to Care report.

HIW confirms the health board has made changes to improve its governance and reporting structure, particularly in terms of escalation of concerns to board level and the sharing of learning at an operational level throughout the health board. However this progress needs to be more rapid. 

A new executive team is in place at Abertawe Bro Morgannwg UHB and I am assured they are taking forward improvements in the areas highlighted by HIW and are committed to getting it right to ensure the quality and safety of care provided to patients is at the heart of what they are implementing. 

The report makes 24 recommendations, three of which fall to Welsh Government to implement on an all-Wales basis.

I expect the health board to take full account of the findings and recommendations from this report; ensure that they are addressed and to embed changes to policies and procedures. 

The NHS Delivery Unit will continue to work with the health board to provide support to ensure it meets the recommendations in full.  

The health board must provide assurance about its quality and safety governance arrangements, including scrutinising safeguarding concerns. This will be verified by inspection processes.

At an all Wales level, I accept the three recommendations for the Welsh Government in their entirety.

Patient safety is of paramount importance; robust safeguarding and governance processes are essential to protect adults at risk.

Completion of Disclosure and Barring Service (DBS) checks and their renewal is an important part of safeguarding patients. I will ask employers and social partners for urgent advice about the most effective way to implement this recommendation across Wales. Once an approach is agreed, these measures will be implemented as quickly as possible.

I have asked the National Independent Safeguarding Board to work with the NHS to further improve existing mechanisms for sharing safeguarding learning.

Work is well progressed by Safeguarding Boards in Wales, supported by the Welsh Government, to deliver safeguarding procedures which build upon existing statutory guidance. I will ask Safeguarding Boards to take account of the findings of this report as part of their work.

I expect all health boards to consider HIW’s findings and recommendations in full.

I am sure this will be very difficult day for the women involved in this case and for their families. My thoughts are with them and I am very grateful for their contribution to this special review.

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