Urgent Debate: The Findings of an Investigation into Patient Care at the Tawel Fan Ward of Bodelwyddan's Glan Clwyd Hospital

Janet Finch-Saunders
Minister, Deputy Presiding Officer, I have to say that the Donna Ockenden report is probably the most heart-breaking cataloguing of some of the worst cases of negligence, institutional abuse and management failure that I have ever borne witness to. To learn of such lack of professional, dignified and compassionate care for the most vulnerable in our society leaves me feeling very heartbroken for the families and for those suffering at the hands of those whom they trusted.

Patients left unsupervised, some nursed on the floor, furniture used as a restraint: painful evidence from families revealing that their loved ones were badly bruised and left to run around the ward naked. One of the families said their loved one was sat in a chair, only had a pair of shorts on and was freezing, ‘So, I went to get him some pillows and a blanket to put over him’, but they couldn’t find a blanket.
For me, as well, it’s about the continence issues—shocking scenes in which a patient who was fully continent prior to admission became doubly incontinent within days. A poster from inside the clinical supplies cupboard read:

‘“STOPNOW!!!” Stop using pull up pads on whoever you fancy. They are certainly NOT for putting one on top of another with knickers on top for your convenience’.
This was a note to medically trained staff. But perhaps most disturbing of all is one family’s account of when their relative sustained an infected, painful and swollen elbow due to constantly crawling around on dirty floors where other patients had urinated and more.

Now, this investigation found that there were multiple examples of inappropriate and unprofessional use of the POVA policy—yes, the protection of vulnerable adults—with staff actually using this as a protection for their own failings. One former member of staff saying:

'We know it's going to come, we know there's going to be a massive complaint again, so that's why we POVA'd ourselves’.

This is a tragic and shameful betrayal, as I say, of those suffering and their loved ones. For their loved ones to speak up and yet to be ignored is another betrayal.
Despite many of the problems having been flagged up, in March 2012 a report by Professor Robert Poole concluded that there were marked limitations in the current serious untoward incidents surveillance system. The families of Tawel Fan’s patients are now quite rightly calling for those responsible for the abuse never to work in care again and I endorse their request—also the point that Darren Millar made earlier: those who have committed these atrocious crimes, as far as I’m concerned, under the guise of doing their employment, should actually now face whatever punishment they deserve.

Now, it says in the report that requests about investigation—numerous requests were made for information on incidents and passed down the operational administration and governance team, instead of actually finding their way up to the level of responsibility. For me, we know the report is there for anybody to read, as tragic as it is. But have any lessons been learned now? What concerns me is that there’s been a strategic review of older people’s mental health services for the board in respect of this, and yet, even now, it is saying:

‘There is no clearly defined or identifiable strategic commissioning function’
within Betsi Cadwaladr.

‘Its internal planning arrangements for OPMH were described as “a movable feast” i.e. responsibilities are dispersed across several management posts with no clear definition of strategic roles and tasks.’

And
‘There is no consistent or credible senior level engagement across sectors’.
And that’s now.

Health Inspectorate Wales visited in April 2015. The on-call system to deal with emergency situations was not well known to staff. This system enables staff to contact the correct person in any circumstance, as well as the local nurse/alarm-call systems needing a review in terms of location and access. There are still privacy and dignity issues now. An ongoing recommendation—now, from 2015—is that all patients are to be given a named nurse and to receive an orientation to the ward. In addition, vision panels indoors should be closed with the control on the inside of the patient’s room. That hardly looks to me as though—. Those are basic fundamentals, and it hardly looks to me as though there’s any sort of urgency here.

I would echo calls now for special measures, and I can tell you I’m in possession of a letter from Llandudno Town Council, written recently to the First Minister, saying the council has resolved to record a vote of no confidence in Betsi Cadwaladr university health board and that it believes that the Welsh Government should intervene in the administration of the Betsi Cadwaladr university health board. I endorse that request, and I endorse the earlier request made here today. The buck stops with you, Minister. Please intervene and ensure that there are special measures placed on the Betsi Cadwaladr health board, because I do wonder: how bad does it have to get? How much must our patients and their families have to suffer before you actually take full responsibility and take some action?