As we await the latest, taxpayer funded, shenanigans employed by Betsi Cadwaladr University Health Board in their attempt to conceal the #Holden report into institutional abuse at the #Hergest mental health unit at Ysbyty Gwynedd, it may be useful to take a look at a more recent report into North Wales mental health units.
One such report is the - 'Independent Investigation into the Care and Treatment Provided on Tawel Fan Ward: a Lessons for Learning Report.'dated May,2018.
There appears to be a disconnect between part one of the report - excerpts in italics - and the report's final findings and conclusions reached. When the report was released, there were many vocal cries of a coverup and a whitewash.
The Investigation was commissioned initially to examine specific concerns raised by some 23 families about the care and treatment received by their loved ones between January 2007 and December 2013...... In order to identify any other patients whose care and treatment might have fallen below an acceptable standard the Investigation was also asked to examine the archives developed during the following prior processes:
The majority of witnesses who were called to give evidence cooperated freely with the Investigation; however a significant number (some 20 percent) did not.
At the inception of the Investigation it was thought that the archives of all prior inquiry and review processes were complete, available and ready for analysis; this was not the case. It took 14 months (from August 2015 to October 2016) for the complete North Wales Police archive to be made available to the Investigation.
There were also ongoing issues in accessing a complete set of formal concerns, incident and safeguarding documentation from both BCUHB and the Local Authorities. Some of this information was only made available to the Investigation as late as July 2017.
The Investigation Panel expected to source documentation from ‘locked down’ archives when the work commenced. At the inception of any NHS investigation there is a requirement that all pertinent documents are identified, recalled and secured; this is commonly known as the ‘lock down process’
...Continued security and monitored access is essential to make certain confidential documents are stored safely so that no suggestion of tampering with evidence can be made against either the organisation or an individual, during the course of an investigation, or at any point in the future.
The Investigation Panel was surprised to find that (initially) documents had not been formally ‘locked down’ in accordance with commonly accepted NHS good practice.
Ockenden External Investigation: a file of documents was provided to the Investigation by BCUHB. However on close examination the archive did not appear to be complete. This was resolved by establishing direct contact with Donna Ockenden and no further delays were incurred.
North Wales Police Investigation: the original archive given to the Investigation had been provided directly to BCUHB by the North Wales Police. The assumption was made by the Health Board that this archive contained copies of all statements provided by its staff together with those provided by the families of patients who had been admitted to Tawel Fan ward between January 2011 and December 2013; at this stage BCUHB thought the archive was complete.
On close examination it became evident to the Investigation Panel that this was not the case.
...During November 2015 discussions were held between the Investigation Chair and the North Wales Police to establish how many statements were missing from the archive given to BCUHB. There ensued a long process which entailed multiple discussions, meetings and written communications.
Eventually at the end of May 2016 the North Wales Police allowed members of the Investigation Panel (via a supervised read at the Police Head Quarters) access to a further 70 witness statements
As a result of this supervised read another 20 patients were identified where families had either clearly raised concerns about the care and treatment provided on Tawel Fan ward, or where material within the statements related to matters which the Investigators determined required further investigation despite no explicit or direct complaint about the matter having been made.
Investigation Panel members were permitted to take brief notes at the Police Headquarters and to list the new patient names. It was agreed by the North Wales Police that the Investigation could share these names with BCUHB so that a search could commence for their clinical records. The Police held a full list of family contact details which it was prepared to share with BCUHB directly.
At this stage, however, the Police wanted to gain the consent of each individual who had given a statement prior to any further information sharing taking place with the Health Board and prior to the additional 70 statements being added to the archive.
The Investigation Panel worked initially with the following departments and organisations to establish a credible witness management process to ensure that all future investigation work adhered to United Kingdom best practice:
BCUHB Workforce and Organisational Development Directorate
The Nursing and Midwifery Council (NMC)
The Royal College of Nursing
The British Medical Association
UNISON
Part one of the report concludes with this worrying paragraph. My emphasis in bold.
The Investigation conducted its work in private and communicated headline findings to BCUHB only towards the end of the investigation process. During the course of the Investigation corporate members of the Trust Board were called as witnesses. The Independent Oversight Panel ensured quality monitoring processes were deployed and held at arm’s length from the Health Board. This guaranteed that the work was completed in a satisfactory manner whilst maintaining the total integrity of the Investigation’s independence. The Betsi Cadwaladr University Health Board received the report after all due process was completed and was not permitted to exert any influence over the Investigation or the report findings and conclusions.
********************
I have read and reread this statement several times and whilst I understand its inclusion its length and tone concerns me. Is there a history of BCUHB interference in investigations as other local government agencies in North Wales have done ?
My own experiences of 'independent' investigations in North Wales, where investigators are bullied and overwhelmed to alter critical reports, interference by senior managers in the process and staff that lie to cover for poor behaviour with the support of their managers leaves me sceptical of many reports published by local government and their agencies.
Would I trust the Hascas report ?
No - and it is my opinion that the reason BCUHB is fighting tooth and nail not to publish the Robin Holden report is because it will simply confirm the claims of some staff and witnesses to the alleged institutional abuse within the North Wales mental health units.
The link to the full report can be found here - HASCAS report, May 2018 (eng).pdf
The file is a PDF document and will be downloaded to your computer and not open as a new web page.
One such report is the - 'Independent Investigation into the Care and Treatment Provided on Tawel Fan Ward: a Lessons for Learning Report.'dated May,2018.
There appears to be a disconnect between part one of the report - excerpts in italics - and the report's final findings and conclusions reached. When the report was released, there were many vocal cries of a coverup and a whitewash.
The Investigation was commissioned initially to examine specific concerns raised by some 23 families about the care and treatment received by their loved ones between January 2007 and December 2013...... In order to identify any other patients whose care and treatment might have fallen below an acceptable standard the Investigation was also asked to examine the archives developed during the following prior processes:
The majority of witnesses who were called to give evidence cooperated freely with the Investigation; however a significant number (some 20 percent) did not.
At the inception of the Investigation it was thought that the archives of all prior inquiry and review processes were complete, available and ready for analysis; this was not the case. It took 14 months (from August 2015 to October 2016) for the complete North Wales Police archive to be made available to the Investigation.
There were also ongoing issues in accessing a complete set of formal concerns, incident and safeguarding documentation from both BCUHB and the Local Authorities. Some of this information was only made available to the Investigation as late as July 2017.
The Investigation Panel expected to source documentation from ‘locked down’ archives when the work commenced. At the inception of any NHS investigation there is a requirement that all pertinent documents are identified, recalled and secured; this is commonly known as the ‘lock down process’
...Continued security and monitored access is essential to make certain confidential documents are stored safely so that no suggestion of tampering with evidence can be made against either the organisation or an individual, during the course of an investigation, or at any point in the future.
The Investigation Panel was surprised to find that (initially) documents had not been formally ‘locked down’ in accordance with commonly accepted NHS good practice.
Ockenden External Investigation: a file of documents was provided to the Investigation by BCUHB. However on close examination the archive did not appear to be complete. This was resolved by establishing direct contact with Donna Ockenden and no further delays were incurred.
North Wales Police Investigation: the original archive given to the Investigation had been provided directly to BCUHB by the North Wales Police. The assumption was made by the Health Board that this archive contained copies of all statements provided by its staff together with those provided by the families of patients who had been admitted to Tawel Fan ward between January 2011 and December 2013; at this stage BCUHB thought the archive was complete.
On close examination it became evident to the Investigation Panel that this was not the case.
...During November 2015 discussions were held between the Investigation Chair and the North Wales Police to establish how many statements were missing from the archive given to BCUHB. There ensued a long process which entailed multiple discussions, meetings and written communications.
Eventually at the end of May 2016 the North Wales Police allowed members of the Investigation Panel (via a supervised read at the Police Head Quarters) access to a further 70 witness statements
As a result of this supervised read another 20 patients were identified where families had either clearly raised concerns about the care and treatment provided on Tawel Fan ward, or where material within the statements related to matters which the Investigators determined required further investigation despite no explicit or direct complaint about the matter having been made.
Investigation Panel members were permitted to take brief notes at the Police Headquarters and to list the new patient names. It was agreed by the North Wales Police that the Investigation could share these names with BCUHB so that a search could commence for their clinical records. The Police held a full list of family contact details which it was prepared to share with BCUHB directly.
At this stage, however, the Police wanted to gain the consent of each individual who had given a statement prior to any further information sharing taking place with the Health Board and prior to the additional 70 statements being added to the archive.
The Investigation Panel worked initially with the following departments and organisations to establish a credible witness management process to ensure that all future investigation work adhered to United Kingdom best practice:
BCUHB Workforce and Organisational Development Directorate
The Nursing and Midwifery Council (NMC)
The Royal College of Nursing
The British Medical Association
UNISON
Part one of the report concludes with this worrying paragraph. My emphasis in bold.
The Investigation conducted its work in private and communicated headline findings to BCUHB only towards the end of the investigation process. During the course of the Investigation corporate members of the Trust Board were called as witnesses. The Independent Oversight Panel ensured quality monitoring processes were deployed and held at arm’s length from the Health Board. This guaranteed that the work was completed in a satisfactory manner whilst maintaining the total integrity of the Investigation’s independence. The Betsi Cadwaladr University Health Board received the report after all due process was completed and was not permitted to exert any influence over the Investigation or the report findings and conclusions.
********************
I have read and reread this statement several times and whilst I understand its inclusion its length and tone concerns me. Is there a history of BCUHB interference in investigations as other local government agencies in North Wales have done ?
My own experiences of 'independent' investigations in North Wales, where investigators are bullied and overwhelmed to alter critical reports, interference by senior managers in the process and staff that lie to cover for poor behaviour with the support of their managers leaves me sceptical of many reports published by local government and their agencies.
Would I trust the Hascas report ?
No - and it is my opinion that the reason BCUHB is fighting tooth and nail not to publish the Robin Holden report is because it will simply confirm the claims of some staff and witnesses to the alleged institutional abuse within the North Wales mental health units.
The link to the full report can be found here - HASCAS report, May 2018 (eng).pdf
The file is a PDF document and will be downloaded to your computer and not open as a new web page.
