#BCUHB Protecting Whistleblowers Or Their Managers ?

A recent #QSE report from the Betsi Cadwaladr University Health Board casts a little more light on the debacle surrounding the Robin Holden report, completed in 2013 but still not released by BCUHB, even after the recent Information Commissioner's Office ruling to publish under the FOIA. 

BCUHB have appealed this decision and a tribunal hearing is expected in early 2021.

The Quality, Safety & Experience report makes mention - 
It is vital the Health Board is able to give confidence to its community and stakeholders that the recommendations from the Holden Report (2013) have been implemented and sustained. The Executive Medical Director and Executive Director of Nursing and Midwifery/Deputy CEO have commissioned work to validate that the recommendations have been implemented and remain in place at this current time...

...This work, due to the need to robustly validate the evidence, is aiming to be completed by the end of September for executive scrutiny and reporting to the QSE Committee at its next meeting in October 2020.

The report, authored by Matthew Joyes, Acting Associate Director of Quality Assurance who is also the Assistant Director of Patient Safety and Experience at the health board is titled 'Holden Report - Update' and is for the attention of Responsible Directors, in this case - David Feanley, Executive Medical Director and Gill Harris, Executive Director of Nursing and Midwifery/Deputy Chief Executive.  

Bearing in mind, the Holden report was completed 7 years ago, it is concerning that only now 'responsible directors' are working towards ensuring that Holden's 19 recommendations have been implemented and sustained within the regions Mental Health Units.

Or is this ongoing work only now taking place to circumvent the ICO tribunal next year by presenting 'evidence' that all is now well in the mental health field and argue that the matter should be closed ? 

The update states that the Executive Director of Nursing and Patient Services made a personal visit to the Hergest Mental Health Unit in July, 2013, in order to speak to a number of staff who had raised concerns. A letter, dated 26th July, 2013, confirmed the exact nature of the allegations made by staff, also informing of a staff members petition of "No confidence in the Managment of the Mental Health Clinical Programme Group in their dealings with the Hergest Unit."  

The claimed institutional abuse within the BCUHB units, that included frail, elderly with dementia alongside other mental health patients, not only affected patients but staff, too.

Who were the managers responsible for the Mental Health Clinical Programme Group that failed so terribly ? Are the actions of BCUHB only to protect the managers and not the whistleblowers as claimed ?

Something is very wrong within the local government organisations of North Wales.

Tawel Fan And The Hascas Report - #BCUHB

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.