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A tragic, avoidable scandal: Why hasn’t a report into a Welsh mental health unit been released?

29 Sep 2021 5 minute read
Ysbyty Gwynedd

Llŷr Gruffydd, Plaid Cymru Senedd Member for North Wales

Mental health services present one of the greatest challenges for our NHS – and sadly it’s a growing challenge.

That’s why it’s important we learn lessons from previous experiences and we are honest in acknowledging mistakes and failures.

Mental health services in the north of Wales were identified as one reason why Betsi Cadwaladr health board needed to be taken into special measures more than six years ago by the First Minister, who was then the health minister.

That was a clear statement and an acknowledgement of previous failings and mistakes. In that respect, the move was to be applauded – even if it was inevitable.

What concerns me now is that – six years on – we are not seeing progress in this sector. Instead, I fear we are seeing a culture of cover-up and a refusal to accept responsibility at the very highest level of both government and health board.

That’s why I’ve called a short debate in the Senedd today focussing on the failure to release the Holden Report by Betsi Cadwaladr health board. It’s symptomatic of a wider problem.

The report was compiled back in 2013 after dozens of health workers came forward to blow the whistle on poor practice at the Hergest mental health unit at Bangor. Their testimony amounted to 700 pages of damning evidence that mental health patients were not getting the treatment they needed and deserved.

In addition, vulnerable elderly patients with mental health issues were being placed side by side with drug addicts and people with other severe needs in an inappropriate way. Staff were unable to complete Datix forms – internal forms for reporting problems – because of time constraints so the problem was allowed to fester by senior management.

It was a recipe for disaster and that disaster ultimately involved patients taking their own lives because of ligature risks that should not have been there.


You would imagine that a report into this kind of problem would be able to identify solutions and responsibility. I’m sure it did, but I can’t be sure because that report has never seen the light of day.

To this day, Betsi Cadwaladr health board is refusing – despite requests and now demands from the Information Commissioner’s Office – to release the report. To my knowledge, not one manager has been directly disciplined, although last week it was revealed that two managers were moved from their posts.

This failure to take accountability for any failings has been a symptom of this whole sorry affair and, instead of demanding managers take responsibility, we’ve seen that whistleblowers have been scapegoated.

Crucially, the same risks that sparked the Holden report eight years ago have not been eliminated from the unit.

This has consequences, serious consequences. Earlier this year a woman from Caernarfon took her life on the unit. She was able to do so because the same ligature risks that were present a decade ago had not been eliminated, despite being identified in the Holden Report.


Now, this would be an internal health board issue was it not for two things. And that’s why it’s important that this is raised in the Senedd today.

Firstly, as I mentioned, mental health services in North Wales were already a subject of sufficient concern six years ago for that to be cited as a reason for the Welsh Government to take the health board into special measures. So this Government was aware there was a problem.

More specifically, last year Eluned Morgan – in her capacity as minister for mental health – gave me assurances in this chamber that she had read the report.

I have no reason to doubt that, so I would ask the minister – who is now health minister – to explain:

  • why the report has not been made public,
  • why the recommendations have not been carried out and
  • why people are still dying on a mental health unit when the risks should have been eliminated.

This is a tragic, avoidable scandal.

It’s a scandal because nobody has been held to account for the failings. These are not the failings of over-stretched frontline staff. These are the long-term failings of senior managers who have continued to be employed by Betsi – some of whom have very senior roles within the health board.

It was avoidable because staff, families and Holden had raised the alarm many years earlier.

The tragedy is that action was not taken. And that means that vulnerable people are still dying on mental health units. I use the plural because in the past year, we’ve seen deaths on Hergest and also on the Ablett unit in north Wales.

We have seen glacial progress in terms of getting the facts out into the open. It’s time this Government showed some leadership and held their hands up on Holden. Let’s have this report out in the open so that we can see for ourselves what needed doing back then and what needs to be done now to deliver better mental services here in the North.

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Huw Davies
Huw Davies
2 years ago

Risk identified 10 years ago has not been ‘sorted’. Who exactly is responsible for making the required changes? What exactly does ‘special measures’ mean in practice? I’d assumed experienced troubleshooters would descend on the health board and get things put right. It sounds more like some toothless assessment with recommendations in a report that is then left to the same health board people to implement, presumably with the same resources and the same staff, with the same ethos and, presumably, the same six figure salaries for the ‘best’ managers. Special Measures seems more like the Senedd’s way of distancing itself… Read more »

Mab Meirion
Mab Meirion
2 years ago
Reply to  Huw Davies

It will be interesting to see how the Baroness responds…

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