‘We must learn from our mistakes’, says Welsh health board in response to damning report

Richard Evans, local democracy reporter

Betsi Cadwaladr University Health Board has said it must learn from its mistakes in the wake of a damning internal report.

The Holden Report concluded in 2013 that patients at Ysbyty Gwynedd’s Hergest psychiatric unit were put at risk, following a breakdown in relations between staff and managers, bullying accusations and low morale.

Whilst a redacted summary was released in 2015, a fuller version was only finally published last week – following negotiations between the health board and the information commissioner, who agreed to omit staff names.

The health board’s vice chair Lucy Reid said processes had been updated but added lessons must be learned: “This was many years ago, and services have changed considerably since then, but it’s important for our population, patients and partners that we are able to clearly demonstrate that we have learnt from and implemented recommendations made from any of our reviews, regardless of how the concerns originated.

“We have now got a new process in place, which involves a review agreement between the chair, myself, the chief executive and deputy chief executive to look at the terms of reference for any external reviews that need to be undertaken.

“I really welcome the intention for all these reviews in future to be commissioned on the basis that they will be able to be made public.”

‘Going to make mistakes’

She added: “The health board is going to make mistakes. All NHS organisations make mistakes, but what is paramount is that we are able to demonstrate learning from those mistakes, and that is what we need to be focusing on going forwards in order to provide confidence in our partners and stakeholders, so I’m glad that this is now being published, and I hope this will give people more confidence that we actually will be delivering what we say we will be delivering.”

Executive director of nursing Gill Harris added: “We are absolutely committed to being open with our community, and at the same time, we need to protect personal data as we are required to do so. The mutual agreement with the information commissioner allows us to do both.

“We have reflected long and hard on the circumstances around this report and the impact of not publishing it has had on our community, including our staff.

“Staff raised legitimate concerns that as a board we need to ensure any action we took to publish did not undermine the confidence of those staff and other staff to raise concerns in the future. This is really important to ensure that our staff are protected when they do so and would (otherwise) risk patient safety.

“Taking a learning from this report, we’ve decided that similar reports will now automatically be written for public release through the appropriate committee.”