Written Statement - Learning from the review undertaken by Abertawe Bro Morgannwg University Health Board into the Kris Wade case

Assembly Members will be aware that Abertawe Bro Morgannwg University Health Board (ABMU) has recently published an internal review looking into the employment history and the management of 3 separate allegations of sexual assault made against an employee, Kris Wade (KW) by 3 former patients within their learning disability service. All 3 allegations were referred by the health board to the police. Following each investigation the criminal justice authorities decided not to pursue a prosecution.

In March 2016, whilst suspended from work pending the conclusion of disciplinary proceedings, KW was arrested on suspicion of murder and later convicted and sentenced to life imprisonment. Following his conviction and dismissal the health board agreed the need to review the effectiveness of the processes surrounding his employment and the management of the allegations made against him. This included determining whether there had been any conflicts of interest throughout this time as the father of KW was the director of the learning disability service at the time.

The review concluded that KW’s future conduct and behaviour outside of his employment could not have been predicted or prevented. However it has clearly identified a number of significant issues of concern and weaknesses relating to governance, adult safeguarding, recruitment, culture and incident reporting and concluded there were several areas for learning and improvement. An improvement plan outlining actions taken to date has been published alongside the report.

This report provides a stark reminder to ensure that the policies and procedures in place in this area are fully understood by all staff and that their implementation and application is regularly monitored. It is clearly essential that we take all appropriate steps to ensure that all NHS organisations learn from it.

All NHS Chief Executives have been asked to review the findings of this report and provide assurance that good governance is in place in relation to patient safety incident reporting, safeguarding and employment practices and that all appropriate guidance is followed to protect the safety of patients, including their sexual safety. They have been asked to provide such confirmation by Friday 29 September.

In respect of ABMU specifically, I want to be satisfied that appropriate actions have been identified by the health board and that their response is sufficiently robust. I also wish to be assured that there are effective arrangements in place across the organisation to monitor the implementation and embedding of any changes in policies and procedures.

I have therefore asked that Healthcare Inspectorate Wales (HIW) undertake an independent assessment to determine:

• if all appropriate learning has been identified from the findings reached in this review
• if the actions being taken are sufficiently wide ranging and robust
• if there are effective arrangements in place for ongoing monitoring of the actions taken, ensuring they are embedded in practice across the organisation
• if there is any further learning that should be shared across the NHS in Wales.

I will update members when the HIW report is received.

Desktop Review and Lessons Learned Report.pdf