Vaughan Gething, Cabinet Secretary for Health and Social Services
This investigation was commissioned by Betsi Cadwaladr University Health Board (BCU) in August 2015 as part of the Putting Things Right process. The HASCAS investigation was initially asked to examine specific concerns raised by 23 families about the care and treatment of their relatives on the Tawel Fan ward between 2007 and its closure in December 2013. HASCAS were also asked to extend the investigation to include consideration of the archives of 3 other related processes to identify other patients whose care and treatment might have fallen below acceptable standards. A total of 108 patients and a number of staff were considered in detail as part of HASCAS investigation.
The HASCAS report is the product of a very extensive and lengthy process involving 108 case reviews, 148 interviews and the review of around 700,000 pages of documentation. It considered the material provided as part of the Ockenden report published in May 2015; a North Wales Police investigation concluded in 2015 and a mortality review conducted by BCU in 2015.
This report provides the thematic findings of the HASCAS investigation. HASCAS will also produce separate reports for the families of each of the patients falling within the scope of this investigation. Those reports will provide the specific analysis of the care of each individual patient and these reports will be shared with families.
This thematic report sets out a very clear rationale for HASCAS’ findings, together with their detailed conclusions, lessons for learning and recommendations. Whilst the report does provide the very important reassurance that they could not substantiate previous claims of patients of Tawel Fan being the victims of institutional abuse or neglect, it does reinforce with even greater clarity some of the findings of previous governance and inspection reports.
In this report HASCAS describe the very considerable journey that BCU has needed to embark on to improve the governance and clinical oversight arrangements established for the organisation at the time of its establishment in 2009 - again demonstrating that they were not fit for purpose. However, the methodology deployed in this investigation enables HASCAS to go further than other reports and very starkly set out where these failings have compromised care in some important areas.
Given the genesis of this investigation, it most closely examines the care provided on Tawel Fan. However, by listening to those families who came forward, it has been able to undertake a detailed analysis of the care pathway for elderly patients. By so doing, it has been able to throw a spotlight on shortcomings that extend beyond those within the remit and control of mental health services. It highlights the need for more rapid attention to secure improvements across a range of areas, whilst recognising that work is underway to address some of issues raised. Overall the report makes it very clear there is still some way for the BCU to go on this improvement journey and this will require further focused oversight under the special measures arrangements.
I would urge caution in jumping to conclusions about the apparent contradiction in the conclusions of the HASCAS investigation and some earlier reports and findings. Those reports focused on smaller cohorts of patients, did not have access to the very comprehensive set of documentation (including clinical records) and other evidence examined as part of the HASCAS investigations – nor were they able to draw in specific mental health expertise.
This is a very substantial report that warrants careful reading and consideration to fully understand why HASCAS has reached the conclusions it has published today. Elements of these HASCAS findings should act as a wakeup call for other NHS organisations and safeguarding partners both in Wales and elsewhere in the UK. It offers a mirror for them to hold up against their care pathways and practices for elderly patients living with dementia and the support provided for their families and carers.
Whilst this will be very difficult day for both families and staff of BCU who were involved or affected by the investigation, I would hope that these HASCAS findings can act as a catalyst to the lifting of a dark shadow that has extended over mental health services in North Wales for a number of years. This shadow has resulted in the population of North Wales losing confidence in their local services and the staff who provide them. BCU and other partners still have a great deal of work to do together to restore that confidence.
I discussed this report’s findings and my expectations for the response from BCU with the Chair and Chief Executive just prior to the Board’s receipt of the report yesterday. I will be discussing next steps with them further over the coming days and I will be making an oral statement next week.