Deaths blamed on health board improvement failures

Mr Dickaty said it was "extremely distressing" that things still had not been done

Families have warned a health board that more patients could die if lessons about poor mental health care are not learned.

A report by the Royal College of Psychiatrists found less than half of 84 recommended improvements to a hospital trust’s mental health department have been made.

In the past 10 years, four separate reviews have outlined changes to be implemented by Betsi Cadwaladr University Health Board. Patient watchdog Llais said people had continued to die during this time.

At a meeting in Llandudno on Thursday morning, the health board, which runs the NHS in north Wales, apologised to families and said it was committed to improving.

Problems with mental health services at the health board first became public in December 2013 when the Tawel Fan dementia ward at Ysbyty Glan Clwyd near Rhyl was closed.

A report said elderly patients there were treated "like animals in a zoo".

Before that, the board was aware of problems at Hergest mental health unit at Ysbyty Gwynedd in Bangor.

An investigation found a culture of bullying and low morale, which meant patient safety concerns were not addressed.

Four separate inquiries from 2013-2018, made recommendations for action.

In the past few months, the Royal College of Psychiatrists has examined whether those changes have been put in place.

Of 84 recommendations, evidence showed only 37 (44%) had been fully implemented.

There was some evidence for 41 changes (49%) being put to effect and none for the remaining six (7%) recommendations.

Phill Dickaty's mother died on the Tawel Fan ward in the grounds of Ysbyty Glan Clwyd

During the meeting earlier, Phill Dickaty, who’s mother Joyce Dickety died on Tawel Fan in 2012, told the board families felt “let down again".

"As things stand, despite the passage of time and false reassurances offered by BCUHB, the Tawel Fan families have a real and significant concerns over the lack of progress," he said.

"Be it patient or otherwise, nobody should ever have to endure a situation like Tawel Fan and the atrocities that took place.

"As well as the disappointment felt at the lack of progress, the risk of history repeating itself again in the future weighs heavily in the minds of Tawel Fan families."

Carol Shillabeer, the health board's chief executive, repeated an apology to families at the meeting

The chair of the health board, Dyfed Edwards, told members that allowing families to address the closed meeting was "unusual", but "important".

The chief executive, Carol Shillabeer, repeated publicly an apology to the families by the health board.

She said an action plan would be presented at the health board’s next meeting as well as discussions with patient representative body Llais on how families’ input could feed into the process.

Speaking to BBC Wales after the meeting, Mr Dickaty said: "The best form of apology would be to act on the Royal College of Psychiatrists’ recommendations and implement now."

Geoff Ryall-Harvey from the patients' watchdog body Llais said: "It’s now for the board to deliver and show they are different to the previous board."

Dawn Owen, 46, died in the care of the mental health service in north Wales

The Royal College of Psychiatrists also said Betsi Cadwaladr needed to urgently look at patient safety, particularly the risk of patients trying to harm themselves.

Earlier this month, a coroner found neglect by the health board had contributed to a patient's death at a mental health ward in 2020.

Last year, it was fined after 46-year-old Dawn Owen killed herself at a different hospital.

Mr Ryall-Harvey said: "We have been telling the health board for much of the last 10 years that things have not been done, and things that were claimed had been done had not been done.

"In those 10 years there have been a number of further incidents - the effect has been ongoing, and there have been more tragedies and more lives lost during that period.

"What we need is an independent oversight panel which will confirm when things have been done and when they can be signed off."

In 10 years four reviews have outlined changes to be implemented by Betsi Cadwaladr Health Board

The Welsh government, which last year placed the health board back under special measures, said there had been a "large number" of critical reviews, reports and a prosecution regarding mental health and disability services at Betsi Cadwaladr.

Due to the special measures, it commissioned a review into the health board's mental health services.

"The health board has accepted the review's key findings and we expect them to deliver those while continuing to make progress in implementing safe and effective policies across its mental health services," it added.

Ms Shillabeer said the board welcomed the review.

"Whilst much progress has been made there is more to do and the board is determined to take action that improves services, which we will do together with patients, their carers and families."