A report into the care of patients at a mental health ward at a hospital in Denbighshire has found there was "no evidence" to suggest patients suffered from abuse or wilful neglect, despite earlier findings.
The report, carried out by the Health and Social Care Advisory Service (HASCAS) examined the impact on individual patients by speaking to families going back to 2007.
The Tawel Fan ward was closed in December 2013 after concerns were raised about the quality and safety of patient care.
A previous independent investigation by Donna Ockenden in 2015 found evidence of "institutional abuse" with reports that patients were left in soiled clothes and kept like "animals at the zoo".
Betsi Cadwaladr University Health Board said it was "truly sorry" for letting patients and families down and it was subsequently placed into special measures following Donna Ockenden's report.
But this report published today after being commissioned in August 2015 has concluded that there was no evidence to suggest the ward was an environment where abusive practice took place "either as a result of uncaring staff who acted in an inappropriate manner, or due to a system that failed to protect."
It said previous claims of institutional abuse were either:
- incomplete; and/or
- misinterpreted; and/or
- taken out of context; and/or
- based on inaccurate (and at times misleading) information; and/or
- misunderstood with thresholds being applied incorrectly
It said its investigation panel found the Tawel Fan ward was of a good overall general standard even though there were key areas identified where clinical practice and process "required development and modernisation."
The report also criticises the behaviour of some family members who visited the ward over the years. It said their behaviour was of a "totally unacceptable nature" that included offensive and racist language including death threats being made to staff, who "tried to manage these behaviours in a professional manner".
The HASCAS report did find that Betsi Cadwaladr Health Board had failures of systems and governance - not just in Tawel Fan but across the care system.
It concluded adult and dementia services "weren't planned or overseen with the oversight needed" - and that patients often did not receive the right care in the right place at the right time - which led to distress, loss of dignity, delays, compromised care and treatment - and that "these standards were unacceptable".
In a joint statement, the health board's Chairman and Chief Executive said they accept the report's findings and there is still "much more to do to make improvements" across adult services.
Plaid Cymru's Rhun ap Iorwerth said the Welsh Government must take "full responsibility" for implementing the report's recommendations.
Welsh Health Secretary, Vaughan Gething, urged caution over jumping to conclusions about the findings but demanded the health board makes further improvements to its services:
The full report can be read here.