There is an 'ongoing failure of [Betsi Cadwaladr University Health Board] to deal in an appropriately timely way with complaints perceived as very serious by families,' according to a report out today.
The latest paper from Donna Ockenden, looking into the governance arrangements at the health board is highly critical of multiple aspects of how the health board has, and continues to, run older people's mental health services.
The report says the system for raising concerns has been described as ‘shambolic’ and ‘broken' with communication between ward staff and the executive team as 'critically weak' and that "many staff and service users lacked confidence in the ability of the BCUHB Board to navigate the long and difficult road ahead."
The review is the second by Donna Ockenden and the third into services at the trouble health board.
The last report, by the Health and Social Care Advisory Service said there was "no evidence" to suggest patients suffered from abuse or wilful neglect, despite findings in the initial Ockenden report of 2014.
Today's report says: "There was little evidence found by the Ockenden team of any significant ‘lessons learned’ from events on Tawel Fan ward."
It was a review of Tawel Fan which prompted the Welsh Government to put Betsi Cadwaladr University Health Board in special measures. This move was designed to turn the fortunes of the health board around and ensure improvements.
While there is an acknowledgement that some improvements have been made, the report again suggests there is 'little evidence' that such improvements are on a 'sustainable footing'.
The report's author, Donna Ockenden said she found 'significant flaws' in the health board's management structure.