A report exposing extensive problems with patient safety in a north Wales mental health unit has finally been made public after nearly eight years.
ITV Cymru Wales revealed details of the report after receiving a leaked copy last year, but Betsi Cadwaladr University Health Board tried to prevent the report’s publication despite the Information Commissioner’s Office ruling they should be released in 2020.
The health board always maintained that publishing it would breach the confidence of members of staff who contributed to it.
However, following a tribunal this month, the health board has conceded that a redacted version can now be made available to the public.
Alongside publishing the report, Jo Whitehead, chief executive of BCUHB, said: “We acknowledge that the delay in publishing this report has frustrated some of those with an interest in it.
“Having reflected on the way that this has been handled, the board has decided that in the interests of openness and transparency, future reports of this nature will be made public.”
The Holden Report was commissioned in 2013 following a petition by staff on the Hergest Mental Health Unit in Bangor, during a period of severely low morale.
45 staff gave 700 pages of testimony to the report’s author Robin Holden, who noted that many of them burst into tears while giving their evidence.
The concerns identified included:
A lack of understanding from management that patients’ needs always come first
An atmosphere of bullying and intimidation from senior management
Inconsistent medical and staffing cover meaning that the care delivered as a result is basic
Concerns from upset and concerned staff that they are not able to meet the demands of the day
The 14-page document includes evidence that the basic physical needs of patients were not being met, with attention to personal hygiene “at times, neglected.”
The Hergest Unit is described as a “grim” place to work, with one member of staff saying” “I’ve worked with a few nurses and we have all gone home crying”.
Another explained they have “worked flat out and I can do no more.”
Crucially, the Holden report details that staff felt unable to raise these concerns to senior management because they “feel very intimidated and fearful for their jobs if they speak out.”
The report made 19 recommendations including better workplace communication, improvements to the staffing of wards and the care given to elderly patients.
Many of these were described as needing to be “urgently” addressed or resolved.
In her statement, Jo Whitehead said: “Action was taken and remains in place to deliver all of the Holden Report’s recommendations and this has been reported publicly.”
However, a member of staff on the unit told ITV News last year that they didn’t believe changes had been made since the report was written in 2013.
Speaking on condition of anonymity in July 2020, they said: "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."
In June, a letter was written from a whistle blower to the health board’s chief executive that describes a “corrupt and toxic” workplace, where the movement of staff has left the remaining workforce with patient safety concerns.
Holden Report: A timeline of events
Robin Holden writes report on the Hergest Mental Health Unit.
Betsi Cadwaladr University Health Board is placed into special measures because of improvements needed in governance and maternity and mental health services.
BCUHB taken out of special measures and into targeted intervention.
Patient death on the Ablett Unit.
Jo Whitehead becomes Chief Executive.
Patient death on the Hergest Unit.
Member of staff writes anonymously to Jo Whitehead.
Holden Report published publicly.
One of the major problems identified by Mr Holden is the unit’s mix of patients.
BCUHB’s decision to place older people alongside the mental health patients they usually cared for has been described as “unacceptable” and needs to be “urgently reconsidered.”
The report said: “This mix of patients is also troublesome, with young fit behaviourally disturbed patients sharing the same space as older frail people whose needs can get overlooked as staff try to grapple with the challenges of dealing with the more demanding patients.”
While the initial concerns in 2013 predominantly centered around the neglect of the elderly patient population, in the following years it has proven fatal for younger mental health patients.
In the last 12 months, two patients have taken their own lives while under the care of Betsi Cadwaladr University Health Board.
Both were able to do so because of the presence of a type of bed on the wards that are required to care for older people.
Today, the chief executive admitted that “some issues, such as the way we manage the mix of older patients, have proved complex to resolve, due to the design and layout of the Hergest Unit and the staffing resources involved”.
Ms Whitehead continued: “Reports from unannounced inspections of the Hergest Unit by Healthcare Inspectorate Wales show that standards of care, staff morale and leadership arrangements have improved in recent years.
“Despite these improvements, we have much more work to do to enable our dedicated staff to deliver the very best care.
“We’re committed to working closely with our patients, their carers, our staff and partners to address these challenges and build trust and confidence in the mental health services we deliver.”
The political response
Responding to the publication of the Holden report, Llyr Gruffydd, Plaid Cymru’ Member of Senedd for the north region, said: “Now that the report is out in the open, work must begin on restoring the trust of the people of north Wales.
“This starts with the health board and Welsh Government acknowledging the enormity of what it reveals, recognising the erosion of trust in the system, and committing to learning each and every difficult lesson that will come out of this.
“This is about far more than releasing a desperately overdue report, this is about accountability from all in charge of the health board during this most terrible time.”
The Welsh Conservatives’ shadow minister for health Russell George said: “The wait for the full Holden Report has long felt like a saga without end.
“Hopefully, this information will give those affected and their families the peace of mind they have long craved.
“However, that will only come if the Health Board learns lessons from this.
“The way the Board has behaved over the best part of a decade has been unacceptable and demonstrates a transparent pattern of behavior revolving around a belief that they should not be held to account over sustained breaches of patient safety.”