A damning report about a mental health unit that a Betsi Cadwaladr health board kept under wraps for eight years has finally been published.
The Holden Report from 2013, reveals that 42 staff on Hergest Unit in Bangor complained about bullying and intimidation by senior management, lack of staff and poor care standards that were left unaddressed for years.
The whistleblowers came forward to make their complaints after a death on the Hergest unit, but practices were not changed sufficiently to prevent further deaths on the unit.
The report’s author Robin Holden found that “relationships between staff and management at matron level and above have broken down to a degree where patient care is undoubtedly being compromised”.
For years, campaigners – including relatives of patients at the unit – have demanded full publication of the report.
The health board had refused, claiming it needed to protect the identities of whistleblowing staff.
Last year, the Information Commissioner declared it should be made public, which was appealed by the health board. But last week, the General Regulatory declared it had to be released within 14 days.
Plaid Cymru’s Llyr Gruffydd MS has called on the Welsh Government to “step up to act” saying that the problems “didn’t end with this report.”
Llyr Gruffydd, Plaid Cymru Member of Senedd for the North Region, said: “At last the public has had sight of the detail that Betsi Cadwaladr has fought so hard to keep hidden. The whistleblowers have had their wish fulfilled – that the terrible working conditions at the Hergest Unit have been laid bare for all to see, and the tragic consequences have been clearly spelled out.
“Because the culture of bullying and intimidation by senior management didn’t end with this report. Nor did the questions and concerns about patient care end when Betsi Cadwaladr was taken out of special measures – as evidenced by the patient death by suicide in April of this year, whilst in the care of the Hergest Unit.
“This isn’t just about needing reassurance that the lessons of the report have been learned, this is about needing clear evidence that changes have been implemented. Specifically, we need a clear statement from the Health Minister and Betsi Cadwaladr health board that they now have a clear and costed plan to put an end to the outdated practice of mixing functional and older adult patients on the Hergest Unit.
“The issues outlined in the report are not an isolated problem but a more systemic issue. Now the report is finally out in the public domain, we need to know that front line staff’s concerns were listened to, that changes were made and that this can never ever happen again. Because the report doesn’t just describe a gap between front line staff and management – it’s a chasm, and the people that fell between the gaps were the health board’s most vulnerable patients. The Health Minister, who saw this report last year and did not act at the time, must now step up to act upon these findings.”
Jo Whitehead, Chief Executive of Betsi Cadwaladr University Health Board, said: “Over recent months we have been in discussions with the Information Commissioner regarding the publication of the Holden Report. Our priority has always been to agree appropriate redaction in order to protect the anonymity of staff that contributed to it, and ensure that all staff have the confidence to raise concerns in future. Having come to an agreement with the Information Commissioner, we are publishing the redacted report in full.
“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.
“Action was taken and remains in place to deliver all of the Holden Report’s recommendations and this has been reported publicly. However, 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. Options are being considered to address this.
“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. In common with other NHS mental health service providers across the UK, we face significant challenges around staffing numbers, managing demand for beds, ensuring the appropriate mix of patients and dealing with the impact of COVID-19.
“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.”
Read the full Holden Report here: https://bcuhb.nhs.wales/about-us/governance-and-assurance/publication-of-the-holden-report/robin-holden-final-report-revised-redactions-applied-v1-0/
Testimony Excerpts: https://bcuhb.nhs.wales/about-us/governance-and-assurance/publication-of-the-holden-report/appendix-a-testimony/
