Tawel Fan : Betsi Cadwaladr's Shame

Little Ward of Horrors.
(Pic : BBC Wales)

Just so you've been warned, the following makes for depressing reading.

Within the last week, a catalogue of serious care failings were revealed in a damning report into the Tawel Fan mental health ward at Denbighshire's Glan Clwyd Hospital, which specialised in "care" for elderly patients with dementia. The ward closed in December 2013 as soon as the seriousness of the allegations became clear, and there are echos with what happened at the Princess of Wales and Neath Port Talbot Hospitals (Abertawe Bro Morgannwg : Trusted to Care?).

The Ockenden Report (pdf)

The report – authored by independent health adviser, Donna Ockenden - was compiled through interviews with families and staff. Some parts have been redacted to protect identities. One thing that stood out immediately were the different opinions on quality of care – 71% of staff expressed no concerns, while only 11% of families described themselves as satisfied or very satisfied with care standards.

Here's what else the review found :

• Lack of professional and dignified care – The ward was noisy, with staff "bellowing" at patients. One staff member is cited as swearing at both patients and other staff members. Doubly incontinent (bowel and bladder) patients weren't given daily showers, and were described as "smelly" – to the point some families had to clean patients with wet wipes. Patients were sometimes left undressed, or not dressed for cold weather. One patient's family were asked over the phone to consider "do not resuscitate" instructions. Some relatives were described by staff as serial complainers who "could always find something wrong".
• Lack of 1-to-1 care (for patient safety) – Some staff were, on occasion, providing one-to-one care for more than one patient, which is reported to have contributed to a patient falling. It seems staff didn't have an understanding of what "one-to-one" care meant. Some patients got into fights with each other and this was brushed off as "something they do"; other patients wandered corridors unsupervised.
• Lack of sufficient nursing levels – Sickness levels were extraordinarily high, leading to staffing shortages as "nobody wanted to be there". Senior managers weren't informed of staffing problems when they were supposed to. Various patients had lumps, bumps and bruises which weren't properly explained. One patient kept banging their head against a wall, resulting in bruising, while staff sat in their office or looked after other patients. It seems as though large numbers of patients were kept in a TV room while their bedrooms were locked just so short-handed staff could keep an eye on as many patients as possible.
• Lack of fundamentals of care – Some families were concerned whether their relatives were being properly fed and given fluids, and families weren't allowed to help during meal times. In some cases, long-term medications (i.e. eye drops for cataracts) weren't provided. Though staff described detailed activity sessions, relatives contradict this by saying they didn't see any evidence of organised activities at all – the ward's environment being described as "uneventful, mundane and lacking in stimulation". There's an example of a patient being left in a puddle of stale urine whilst suffering from a chest infection, and was eventually diagnosed with pneumonia. It's implied another patient was over-medicated to the point of being "a zombie....drugged-up and lethargic", while concerns over another patient's inability to swallow appear to have been brushed off.
• Poor safety briefings – The handover between staff shifts were poor. There's a recording of one such meeting where abusive language was used to describe patients and their relatives. One member of staff is recorded as saying they threatened a patient whilst cleaning away cups.
• Breaches of care duties and patients nursed on the floor – One temporary staff member said other members of staff were deliberately "winding up" sexually uninhibited patients for their own amusement. Another patient was left face-down on the floor - a relative from another family asked why they were left there, with staff saying they're "less of a nuisance there". Other patients crawled everywhere or were left on the floor for long periods of time – the floor sometimes covered in urine and faeces.
• Human rights breaches – Restraint was used regularly, with furniture sometimes used (i.e.  pushing patients up against a wall with a table) - the excuse being that it's to prevent falls or to get patients to settle down. Staff referred themselves to Protection of Vulnerable Adults (POVA) procedures to "cover their backs" (on the use of restraint) as they believed complaints were inevitable.
• Systemic failures – A lack of action by senior leadership on previous reports; a lack of systemic review across north Wales to address current and known risks; significant under-reporting of serious incidents; limited oversight of the leadership team on Tawel Fan ward; the culture on the ward amounted to "institutional abuse".

It's reported 8 nurses have been suspended, 4 nurses have been redeployed while 2 doctors have been working "under restrictions". It was also reported yesterday that 10 staff (3 doctors and 7 nurses) have been referred to their respective professional bodies.

The report recommends the ward isn't reopened until the findings of a mortality review are published, and also recommends the ward be renamed. Betsi Cadwaladr LHB should also offer a full apology to the families and patients of those involved, accompanied by a complete overhaul of the complaints system.

The Welsh Government's Response

The Health Minister apologised to families and patients on behalf
of the Welsh Government at an urgent debate yesterday.
(Pic : BBC Wales)

Health Minister, Mark Drakeford (Lab, Cardiff West), was due to issue a statement on Tawel Fan in the National Assembly on Tuesday but this was pulled. AMs subsequently voted on a Welsh Conservative motion to hold an urgent debate on Wednesday (3^rd June), which was agreed unanimously with Welsh Government support.

The result was a very sombre, measured debate that was a credit to the Assembly, leaving a few AMs visibly on the verge of tears.

In his opening statement, the Health Minister apologised for "gross departures from basic standards of care". Most cases of abuse of dementia patients are outside the NHS, but this was located within the campus of a general hospital. Although the police inquiry has ended, that doesn't mean the process ends, though he wouldn't say anything that would prejudice disciplinary actions.

He said five actions had been taken at board level – such as ward closures, disciplinary procedures, new director appointments and an external review of mental health services for older people across north Wales. The Welsh Government extended unannounced spot-checks of mental health wards in north Wales focusing on continence care, use of anti-psychotics and restraints, culture of leadership and activities etc – all issues raised in the report. He believes these checks show poor care isn't a systemic problem and were isolated to Tawel Fan.

An urgent meeting will be held next week between Welsh Government, Healthcare Inspectorate Wales and the Wales Audit Office on the status of Betsi Cadwaladr LHB, where the option to place it into special measures will be on the table.

In order to keep the word count down, and avoid repetition, I've summarised what was said by AMs even more so than I usually do :

• Reactions to the findings : "Shocking", "inexcusable", "horrifying", "stomach-churning", "awful", "inhumane", "patients treated like animals", "requires no sensationalisation", "haunting", comparisons made with Mid Staffordshire, Abertawe Bro Morgannwg and Winterbourne View scandals.
• The Families : The complaints system failed families and patients. Relatives had every right to expect their loved ones to be safe. Families need closure, but there's a need to emphasise that it's not systematic abuse (for relatives of patients currently being treated on mental health wards). There were calls for ministers to meet the affected families.
• Staff & Managers : This was a, "Complete corruption of professional standards". Those responsible should never be allowed to care for patients again; managers should be sacked – not removed or paid off. Nobody should escape scrutiny, though front line staff shouldn't carry the can alone. There were calls for a "fit and proper person test" for NHS managers and/or a regulatory system similar to the General Medical Council. North Wales Police's decision not to prosecute was made before the publication of a mortality reviews and this report, which is unacceptable.
• Healthcare Inspectorate Wales (HIW) : Needs an overhaul, including unannounced inspections which don't require prior ministerial approval. Lay inspectors who offer "fresh eyes" and who are unfamiliar with ward culture should be introduced. Provisions within the Social Services & Wellbeing Act 2014 will help to avoid a repeat of Tawel Fan – but HIW hadn't learned lessons from previous scandals.
• The Welsh Government : Welsh Government have appointed someone to undertake another review in response to a previous review - this calls into question Welsh Government's drive for change. Government needs to "act now" and it has to be better than another report. The Community Health Council say Welsh Government are responsible for strategy, but AMs are told by Ministers these are matters for health boards – no accountability (Accountability vacuum causing problems for Welsh Labour?). There should be an independent appointments process for health board positions to avoid cronyism and ensure it's free of party politics (the Health Minister appoints board and some Community Health Council members).
• Betsi Cadwaladr Health Board (BC) : Numerous cross-party calls for BC to be put into special measures and/or an independent inquiry. Some AMs had no confidence in BC as they're incapable of learning lessons; one AM saying it was "the final nail in the coffin" for the health board.

This is the second major report into failings at the hospital in a month (the other being about out of hours GP care), and I've lost count of how many times BC have been criticised over the last few years.

I accept medical and nursing staff deal with difficult circumstances every day, and as they become desensitised they'll say or do things in private that would appal relatives.

The fact these things aren't isolated to Betsi Cadwaladr though (as said, many findings were identical to those in Abertawe Bro Morgannwg) suggests that in some areas of the NHS – particularly those dealing with the elderly and mental illness - there's a rotten culture developing in nursing and medicine; whether that's down to staffing and morale issues, a failure to do the basics or poor management and training I don't know.

One thing I said with the Andrews Report and the McClelland review of ambulance services, and applies to any business or employer, is that high sickness rates are the biggest red flag of a dysfunctional workplace – if staff don't want to turn up to work something must be wrong and has to be addressed urgently. It's time NHS Wales picked up on that too.

It's clear there are serious problems with the NHS complaints system – as investigated by the Assembly's Health & Social Care Committee last year (NHS Wales : Who watches the watchers?) – and it's come to a point where there needs to be a complete overhaul, possibly backed by legislation.

I've been sceptical about the need for a Keogh-style full public inquiry into the Welsh NHS as I'm worried it would be turned into an Inquisition by the press and Conservatives, and wouldn't be about determining where the problems are and how to fix them. If there were still two or three years left of this Assembly term, I would change my mind.

Instead, the public will get a chance to pass judgement on the Welsh NHS next May.

UPDATE 08/06/2015 : BBC Wales, Western Mail and the Daily Post have confirmed that the Welsh Government have placed Betsi Cadwaladr Health Board in "special measures". It's the first time a Welsh health board has been placed in special measures. Patients and families are unlikely to notice the difference in terms of services, but in practice it means the Welsh Government have taken direct control of the health board.