Mental health: Damning report shows Ysbyty Gwynedd failings

A report into failings at a mental health unit has finally been made public - eight years after it was completed.

In 2013, the Holden Report said a breakdown in staff and manager relations at Hergest Unit, Ysbyty Gwynedd, put patients at risk.

Amid a culture of bullying and low morale, patient safety concerns were not addressed.

Betsi Cadwaladr health board said some issues were "complex to resolve".

A redacted copy of the report's summary was released in 2015, warning the unit in Bangor was "in serious trouble".

The report's author Robin Holden found that "relationships between staff and management at matron level and above have broken down to a degree where patient care is undoubtedly being compromised".

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For years, campaigners - including relatives of patients at the unit - have demanded full publication of the report.

The health board had refused, claiming it needed to protect the identities of whistleblowing staff.

Last year, the Information Commissioner declared it should be made public, which was appealed by the health board. But last week, the General Regulatory declared it had to be released within 14 days.

'Nobody is dead'

The Holden Report was written just a few weeks before health board closed the 17-bed Tawel Fan dementia unit at the Ablett Unit in Glan Clwyd hospital in Bodelwyddan, citing "deeply distressing" allegations about patient care.

The report makes it clear that from the summer of 2013, the health board also knew of major problems between staff and senior management at the Hergest Unit, after 39 members of staff put their names to a petition stating they had "no confidence in the management of the Mental Health Clinical Programme Group".

Most of those who signed the petition were later interviewed as part of the investigation into how the unit was being run.

In statements made by some members of staff about levels of care they are able to provide, one said: "I've done the best I can, I haven't done everything I would have like to have done.

"It's a bit like, nobody is dead, there have been no major incidents, I've worked flat out and I can do no more."

Another said: "If everybody is still alive at the end of the day that's the best I can do."

The report, which made 19 recommendations for change, said there was "inadequate staffing to meet the needs of the patients in the unit, which described as being chaotic; with managers being unresponsive to the situation".

It added: "The mix of patients is also troublesome, with young fit behaviourally disturbed patients sharing the same space as older frail people whose needs can get overlooked as staff try to grapple with the challenges of dealing with the more 'demanding patients'."

One staff member is quoted saying: "On our ward we have a handful of young men in their 20s with 90-year-old ladies with Zimmer frames needing toileting every two hours. Not practical. Not a good mix."

The report says that the investigation was "informed" by previous recommendations made by Healthcare Inspectorate Wales (HIW), the NHS Wales Delivery and Support Unit (DSU), as well as the Hergest Improvement Programme (HIP).

It said the "critical breakdown in communication has created a worrying poverty of leadership in the unit", adding "the current arrangements for the care of frail elderly patients needs to be urgently reconsidered. It is clearly unacceptable for the needs of frail vulnerable people to be neglected in the way that has been reported".

'We have much more work to do'

In a statement, Betsi Cadwaladr health board's chief executive Jo Whitehead said: "We acknowledge that the delay in publishing this report has frustrated some of those with an interest in it.

"Having reflected on the way that this has been handled, the Board has decided that in the interests of openness and transparency, future reports of this nature will be made public.

"Action was taken and remains in place to deliver all of the Holden Report's recommendations and this has been reported publicly.

"However, some issues, such as the way we manage the mix of older patients, have proved complex to resolve, due to the design and layout of the Hergest Unit and the staffing resources involved. Options are being considered to address this.

"Reports from unannounced inspections of the Hergest Unit by Healthcare Inspectorate Wales show that standards of care, staff morale and leadership arrangements have improved in recent years.

"Despite these improvements, we have much more work to do."