A health board failed to carry out adequate pre-employment safety checks on a member of staff who was later alleged to have sexually assaulted vulnerable patients, an internal review has found.
Kris Wade worked in the Learning and Disabilities Directorate of Abertawe Bro Morgannwg University Health Board as a nursing assistant.
He was based in Rowan House, Cardiff, when the allegations were made. Wade later went on to murder his next door neighbour, Christine James, in a 'sexually motivated' attack.
A team reviewing Abertawe Bro Morgannwg's handling of the former employee said it was "unable to locate any evidence this [a CRB check] was undertaken" and that "the likelihood is, no CRB check was ever undertaken" when Wade was assigned a nursing assistant post.
This contradicts a health board statement published after Kris Wade's sentencing for murder, which states: "We can confirm that a criminal records check was carried out before Mr Wade was first employed at Rowan House in 2005."
The review also highlights large gaps in Wade's employment history saying "no information is held regarding how Kris Wade came to secure a full time substantive contract, in what capacity and no information regarding recruitment or application is held or known."
Further failings are identified around the reporting of allegations of sexual abuse by vulnerable patients. The review states of the first allegation, made in 2011, that "there is no evidence that the allegation was escalated" within the health board when the allegation was first made. This was something repeated, the review says, when the same allegation was raised multiple times.
With each allegation, the police were informed, but no criminal proceedings were taken forward.
Following the publication of the review, ITV Wales can reveal that multiple staff had raised issues for years about how concerns were raised and how the health board managed them.
Ray Jacques was a consultant psychiatrist and associate clinical director within the learning and disabilities directorate. One of the alleged victims of Kris Wade, was a patient of his. He's now retired but spoke exclusively to ITV Wales of his concerns around the handling of allegations by ABMU.
ITV Wales can also reveal how the British Medical Association in Wales started looking into the concerns raised back in 2016 and has pushed for months to see the review into Kris Wade.
ITV Wales understands that the review published by ABMU into Kris Wade a couple days ago, was actually finished in January 2017. It was also seen by Welsh Government - who were first informed of concerns about the Learning and Disabilities Directorate back in September 2016.
This has prompted opposition parties to also question how robust the health board's investigations have been and back the BMA's call for an independent inquiry into what has happened.
The Welsh Conservatives leader, Andrew RT Davies said the review showed "a laissez faire attitude to safeguarding and a culture of stubborn unwilling to take seriously the testimony of patients and staff members."
Plaid Cymru have called for 'heads to roll'.
Bethan Jenkins, AM said: "I’m frankly astonished at what I’ve read in this report. This highlights what are clearly systemic failures in patient care and protection. The details regarding the proper reporting and action – or lack thereof – of allegations of sexual assault against Mr Wade from vulnerable patients is damning.
"I think it’s time for heads to roll, frankly. Those with responsibility to report incidents and follow proper procedure - or not as it was in these cases – should go, and those with ultimate responsibility in ABMU should also be considering their positions at the moment. The buck has to stop somewhere and there needs to be accountability for another failure of patient care and protection at ABMU."
ABMU have been asked for comment, but previously said in response to calls for an independent inquiry that "we are surprised and disappointed to hear the BMA is calling for a review in how we investigate formal concerns.
"ABMU Health Board actively encourages all staff to raise concerns about patient safety, and have robust processes in place to support this. We encourage openness and transparency."
It added: "As a health board, it is of course our responsibility to investigate concerns raised in the first place, and when necessary to arrange for external reviews, and we have done this on a number of occasions."
It also said it has made a 'number of changes which have considerably strengthened the recruitment process' since Wade joined the NHS in 2001.
A Welsh Government spokesperson said: "We expect Health Boards to robustly investigate any serious allegations made against NHS staff, and to take appropriate action if necessary.
"In addition, there are clear national policies in place which set out the process for staff who wish to raise concerns. Health Boards are expected to have robust and effective processes and governance arrangements in place to handle any concerns raised.”
ITV Wales will have more, exclusive details and interviews on this story, tonight, on Wales at Six.