Health bosses vow to take urgent action after critical report

Mark Mansfield

Bosses at one of Wales’ largest health boards have promised urgent action after a damning report exposed serious failings in patient safety, leadership and governance.

Cardiff and Vale University Health Board said it was already making changes following the publication of a highly critical assessment commissioned as part of Welsh Government intervention in the organisation.

Interim chief executive Chris Bown said the findings were being taken “extremely seriously” and that areas requiring improvement must be addressed “at pace”.

The health board was placed at Level 4, or targeted intervention, in July 2025 because of concerns over its finances, quality, clinical services, leadership and governance.

NHS Wales Performance and Improvement was subsequently commissioned to carry out an independent assessment to establish the factors contributing to the health board’s position and identify changes needed to support its improvement.

Independent advisers Dr Pamela Johnston and Professor Em Wilkinson-Brice reviewed around 200 documents and spoke to approximately 200 people across the organisation.

Their assessment found clinical governance was “poorly developed”, risk management was underdeveloped and there was an overall failure to hold clinical boards effectively to account.

It also raised concerns over an “excessive number” of Never Events – serious patient safety incidents considered preventable – during the previous two years and found insufficient processes for learning from them and preventing further incidents.

Staff morale was described as the “worst it has ever been”, while the organisation was said to have developed a “pervasive culture of learned helplessness”.

The report described the culture as “siloed, quick to blame others and is divided”, and found some employees were reluctant to raise concerns because they feared negative consequences.

It states: “There is poor organisational psychological safety, and in some areas, there is a fear of speaking up compounded by disrespectful behaviours and poor role modelling.”

Assessors also found a lack of clear decision-making and direction from the executive team and said there was no single plan for the organisation that was understood by staff.

Financial problems were found to have dominated the health board’s focus “at the expense of quality of care”.

However, the assessment recognised signs of improvement under health board chair Kirsty Williams and highlighted the commitment of staff to providing high-quality care.

Mr Bown said: “We take the findings of the report extremely seriously and recognise that there are a number of areas requiring improvement – these must be addressed at pace.

“While work is already underway in a number of the areas identified, we recognise that more needs to be done. The report provides valuable insight into where we need to improve and will help shape our ongoing improvement plans, ensuring they remain focused on strengthening services and improving experiences and outcomes for the people we serve.

“Every day, colleagues make a difference by providing care, support and reassurance during some of the most important and challenging moments in people’s lives. That dedication is recognised within the report, and it provides a strong foundation on which to build the improvements needed for the future.

“We are committed to listening, learning and taking action. By keeping people at the heart of everything we do, we can make lasting improvements for our patients, communities and staff.”

Governance arrangements

The health board said work was already underway to strengthen governance arrangements and support leadership development.

It is also bringing improvement work together through a single Integrated Improvement Plan, which it says will provide a coordinated approach to delivering changes across the organisation.

The independent report itself recommends an organisational “reset” and says a single improvement plan should be finalised and communicated throughout the health board as soon as possible.
It also says a move away from commissioning further reviews towards the “delivery and action of existing plans is crucial”.

Cabinet Minister for Health and Care Mabon ap Gwynfor MS said: “The report identifies concerns across leadership, culture, governance, planning and organisational capability that are unacceptable and must be urgently addressed.

“The report is clear that the health board’s challenges are systemic and long-standing, requiring organisational reset, a single recovery plan, stronger accountability, assurance and cultural change.
“Under this new Welsh Government, we will not allow such issues to continue, and we will robustly hold the health board to account for its performance.”

Reflection

Ms Williams said: “This report provides an important opportunity for reflection, learning and improvement. While it identifies areas where change is needed, it also recognises the commitment of colleagues across our organisation and the progress that has already been made.

“We are committed to being an organisation that listens, learns and continually improves. Working closely with Welsh Government, NHS Wales partners, staff and stakeholders, we will focus on making the changes needed to strengthen our culture, leadership and governance, while continuing to deliver safe and effective care for our communities.

“Meaningful change takes time, commitment and sustained effort, but we are determined to use the findings of this report to build a stronger organisation for the future.

“By learning from what the report tells us and maintaining a clear focus on what matters most to patients, communities and staff, we can continue to improve the services people rely on and strengthen confidence in our organisation.”

Mr Bown, who has more than 35 years of senior healthcare leadership experience, was appointed interim chief executive following the departure of Suzanne Rankin, who is taking up a new NHS role in England.

Mr ap Gwynfor is due to chair a meeting with the health board in November to review its progress.

---

Get more trusted Welsh news

Choose Nation.Cymru as a preferred source in Google News to see more of our journalism.