Campaigner 'mystified' over staff changes in north Wales psychiatric services after patient deaths


The son of a woman who was treated on a beleaguered mental health unit in North Wales says he is “mystified” by the removal of members of staff following the deaths of two patients.

David Graves' mother was placed on the controversial Hergest Unit for psychiatric care in Ysbyty Gwynedd in 2013.

He believes that recent steps taken by Betsi Cadwaladr University Health Board in the wake of two patient deaths “seem to ignore the blindingly obvious conclusions” from reports that point to other decisions leading to “tragic loss of life and harm to the most vulnerable patients.”

David Graves' mother Jean was a patient at the unit in 2013

Mr Graves, who now campaigns for better mental health services, said: "I am mystified by these suspensions... The circumstances they have created and been repeatedly warned will result in harm."

ITV Cymru Wales has seen a letter from a whistleblower to the Chief Executive of Betsi Cadwaladr University Health Board in June that describes a “corrupt and toxic” workplace, where the movement of staff has left the remaining workforce with patient safety concerns.

The letter was written following the death of a patient on the Hergest Unit in April, described by the author as a “never” event and yet came just four months after the death of another patient on the fellow Ablett Unit in Ysbyty Glan Clwyd.

Investigations into both deaths made reference to ligatures and the equipment in the units. Fears over patient safety and ligature risks have been raised as far back as 2014 and in later documents in 2016 and 2018.

Betsi Cadwaladr University Health Board

A timeline of events

  • 2015 - Betsi Cadwaladr University Health Board is placed into special measures because of improvements needed in governance and maternity and mental health services. 

  • November 2020 - BCUHB taken out of special measures and into targeted intervention. 

  • December 2020 - Patient death on the Ablett Unit.

  • January 2021 - Jo Whitehead becomes Chief Executive.

  • April 2021 - Patient death on the Hergest Unit.

  • June 2021 - Member of staff writes anonymously to Jo Whitehead.

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Betsi Cadwaladr Health Board treats older people and mental health patients together in the same units. This policy has been described as creating a “toxic mix of patients” by David Graves, because of the difference in care needs and equipment used to look after both.

Jo Whitehead, Chief Executive at Betsi Cadwaladr University Health Board, said: “We express our deepest sympathy to the families of those patients affected by these two tragic incidents.

"There is an independent investigation taking place and the findings of which will be reported to our public Quality, Safety and Experience Committee. It would not be appropriate for us to speculate on the findings of this independent investigation at this stage.”

Jo Whitehead took up the role of chief executive in January 2021. Credit: Betsi Cadwaladr University Health Board

Ms Whitehead became Chief Executive in January 2021 and has stated that she is “determined to help the Health Board meet its challenges and provide health care services our communities and our staff can be proud of.”

Mr Graves told ITV Cymru Wales he “would like to commend Jo Whitehead on her attempt to turn Betsi Cadwaladr round” and sees her as the gateway to making the Health Board more transparent in addressing the problems in its Mental Health department.

ITV Cymru Wales has also seen Jo Whitehead’s response to the whistleblower letter which detailed a number of findings in the aftermath of the death of the patient treated on the Hergest Unit in April.

These included “unusual language” used to describe the patient’s presentation that did not provide a clear indication of how the patient was feeling, the patient was not on an anti-ligature bed and issues with workforce capacity and capability.

The Chief Executive has ordered an external investigation into the patient’s death and for the Head of Operations and Head of Nursing who oversee the Hergest Unit to be relocated to “an alternative environment.”

In a statement Jo Whitehead said: “We are unable to comment publicly on individual staff matters however we can assure that all staff will be treated fairly and in accordance with our values and policies. We encourage and welcome staff to raise concerns and we are confident the independent investigation will provide the Health Board with objective facts and recommendations.”

But politicians have begun to question the Welsh Government’s decision to take Betsi Cadwaladr Health Board out of special measures in November 2020, just weeks before a patient died on the Ablett Unit.

Plaid Cymru’s spokesperson for health, Rhun ap Iorwerth MS said: "The continued scandals must be urgently addressed, and my heart goes out to all the families that continue to be affected by these tragedies. Questions must be asked how Betsi Cadwaladr was able to come out of special measures when serious problems within mental health units clearly persist.

“Welsh Government must accept responsibility for addressing these long running and deep rooted issues. If no decisive action is taken, these tragic episodes will continue, leaving an ever growing list of bereaved families with unanswered questions.”

Betsi Cadwaladr University Health Board continues to be in Targeted Intervention, the Welsh Government has said.

A spokesperson added: "Improvements have been made, but there are four key areas, including mental health, that require significant action on the part of the organisation and these are accompanied by a level of continued oversight from Welsh Government officials."