Video report by James Crichton-Smith
The death of a patient and a suicide attempt with no doctors available, staff "intimidated" and "fearful" for their jobs.
Those are just some of the damning details of a report leaked exclusively to ITV News which shines a light on how patients were "neglected" at a mental health unit in north Wales.
The mother of a former patient at a north Wales mental health unit has said she "couldn't let" her daughter "go back there" as new details about people being "neglected" there have emerged.
ITV News has seen a leaked copy of the Robin Holden report from 2014.
It was commissioned by Betsi Cadwaladr Health Board after staff on the Hergest mental health unit, which is situated within Ysbyty Gwynedd in Bangor, blew the whistle over management and patient safety concerns.
It reveals details never before made public, about how staff struggled to care for patients.
The document, which the health board has fought for six years to keep out of public view, gives an account of the death of a patient while no doctor was available because of rota gaps, another of a patient who tried to take their own life, again when no doctor was available, and inadequate staffing affecting patient care.
What does the full report say?
The 14-page document is based on 45 staff interviews and 700 pages of witness statements - and until now, only a summary has ever been published.
The full report gives details how staff were "very intimidated" and “fearful for their jobs”.
It goes on to describe how many staff feared for their patients. It states "that basic physical care such as attention to personal hygiene is, at times, neglected."
Staff testimonies in the report say:
The quiet ones [patients] that are actually too ill to speak out, sometimes you sort of forget about them and maybe they haven’t had a drink.
Another quote reads, "Sometimes when people are that quiet they just get left”, and “I don’t feel that I am doing a good job even though I have been struggling to do everything I can.
You know you have done everything you could have done but you know that Mr [X] has been neglected.
If everybody is still alive at the end of the day, that’s the best I can do.
What has been the reaction from families who had loved ones at Hergest?
Families of patients who were on the Hergest Unit have reacted with anger at the report and the health board's continued fight against making it public. They also say that lessons have not been learned and the health board has engaged in a "cover up".
David Graves's late mother, Jean, was a patient on Hergest in 2013.
He has always argued that what she experienced was neglect, but that it occurred because staff simply couldn't deal with the demands placed on them by managers.
Mr Graves told ITV News, "We knew that staff were so busy... that they simply couldn't sit over a patient and make them eat food as we had done with her [his mother] at home."
The staff, even though trying their best, could not provide dignity of care to those particular clients.
Mr Graves said of the health board's refusal to publish the full report, "It doesn't wash. It makes me angry."
"It makes me angry on behalf of the patients who suffered, but it makes me angry on behalf of the people who were brave enough to put their careers on the line and try to get that document brought to the public attention and dealt with openly and publicly.
"You're not going to do anybody any favours by keeping those concerns under wraps, by brushing them under the carpet. That's a serious mistake by anybody who wants to get Betsi Cadwaladr out of special measures."
Sophie Taylor was a patient on Hergest in 2018 while she experienced periods of psychosis.
She believes that despite the Holden findings, lessons are not being learned.
She told ITV News, "It makes me feel awful because nobody chooses to go through this. I was going about my normal life, had a job, hobbies, friends, just a normal person doing my everyday business and it hit me out of nowhere. That could be potentially you, it could be the people in the hospital. It felt like we were just there, we weren't human beings and that we didn't deserve the care and that we weren't worthy of it."
Sophie's mother, Debra, said she fears for the future if Sophie should ever need support again.
She said: "It absolutely breaks my heart to see all those patients there and to me it's like they're shut away, closed away and they're forgotten about and I just think something's got to be done."
I couldn't let her go back there.
"You knew if something went wrong, there would be no support"
Former staff from the Hergest Unit have also told ITV News of their believe that nothing has changed. One said: "There was, and still is, a huge disconnect between the clinical staff and the management."
They continued: "I don't believe anything has changed in the intervening years. There is a toxic, bullying culture where the priority is appearances, rather than an open, learning culture, where staff are valued and listened to."
Speaking on condition of anonymity, the staff member added: "You were made to feel responsible for things that were outside of your control, and you knew if something went wrong there would be no support."
How has the health board responded?
Betsi Cadwaladr Health Board is continuing to stand by its decision to fight an Information Commissioner's ruling from June, which demanded the full Holden report be released.
The ICO ruling said the health board was not entitled to rely on exemptions under the Freedom of Information Act as a way of not making the document public, six years after it was completed.
Defending the health board's position, Interim Chief Executive of Betsi Cadwaladr University Health Board, Simon Dean, said: “We have a duty of care to our employees and are concerned that publishing this full report would breach the confidence of those members of staff who contributed to it.
“Since this report was produced in 2014, we have taken a range of actions to improve standards of care on the Hergest Unit. Reports from unannounced inspections of the unit by Healthcare Inspectorate Wales show that standards of care, staff morale and leadership arrangements have improved in recent years."
Mr Dean said recruitment issues have improved and they are using patient feedback to "drive up standards of care.""Consultant medical cover has also improved and all posts in the West area are currently filled. Through service user and carer organisation Caniad we are using feedback from patients on the Hergest Unit to drive up standards of care. This feedback shows that while we do not always get things right, patients are generally very positive about the care that they have received."We encourage anyone with concerns about the care that they or a loved one have received to contact us directly."
Tawel Fan at Ysbyty Glan Clwyd hit the headlines after revelations of "institutional abuse".
There have since been multiple public reports into how that unit was run, and the Welsh Government has assumed direct control over turning the situation around.
The Welsh Conservatives have now renewed their calls for the report to be published in full.
Darren Millar MS said: “The deliberate attempts to stifle its publication are unhelpful and undermine trust between the Health Board and the people it serves.
"The public have a right to know whether scandals such as Tawel Fan could have been avoided and the publication of this report may help to shed a light on these issues.”
Andrew RT Davies MS added: "After the shocking reports from ITV Wales today, the Holden Report must now be published in full right away."
The health minister, Vaughan Gething declined the opportunity to be interviewed by ITV News about the leaked Holden report.
In a statement, the Welsh Government said: “The Health Board has already taken a number of actions in response to the report’s recommendations. The board is appealing the decision to publish the report to protect staff who raised concerns and contributed to it. An unannounced Health Inspectorate Wales inspection of the Hergest Unit in 2018 found that overall the unit provided safe care.”