1. ITV Report

'No evidence' of institutional abuse at Denbighshire's Tawel Fan mental health ward

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.

The report said it found the ward was of a Credit: HASCAS 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".

There is no evidence to support earlier findings that patients suffered from deliberate abuse or wilful neglect or that the system failed to deliver care and treatment in a manner that could be determined to meet the threshold for institutional abuse.

– HASCAS report

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.

We fully acknowledge that this has been and will continue to be a very difficult process for all the families and staff involved.

Today’s report provides us with a full, evidence-based view that is the result of a comprehensive investigative process which included over 100 interviews of families and staff and over half a million pages of information including police transcripts, medical records, staff records and corporate records.

Since 2013, there have been substantial improvements to the way the Health Board is organised and operates, as well as work to improve the involvement of families and carers, provide better services for people with dementia and the strengthening of our safeguarding arrangements.

However we are clear that we have much more to do to make improvements across all of our adult services – not just mental health services. We have a new executive clinical leadership team in place who, along with the rest of the Board, are resolved to use today’s findings to drive forward the changes needed to provide safe, high quality care that puts the individual patient’s need first.

– BCUHB Chairman Dr Peter Higson and Chief Executive Gary Doherty

Plaid Cymru's Rhun ap Iorwerth said the Welsh Government must take "full responsibility" for implementing the report's recommendations.

This is a damning report about failings in standards of care. Although dismissing the accusation of Institutional abuse and neglect, it is clear that what happened could and should have been avoided. The Welsh Government must now take full responsibility for implementing the recommendations for change with real urgency. Vulnerable people in our society deserve nothing less.

– Rhun ap Iorwerth AM, Plaid Cymru shadow cabinet secretary for health and well-being

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 investigation had a much wider remit and, unlike the previous report, was able to access a comprehensive set of documentation, including clinical records, and draw in specific mental health expertise," he said.

This is a very substantial report that warrants further careful reading and consideration. Whilst this will be very difficult day for both families and staff who were involved or affected by the investigation, I would hope that these 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.

– Vaughan Gething AM, Health Secretary

The full report can be read here.