Betsi Cadwaladr deaths blamed on improvement failures

People have died because an under-fire health board has not improved mental health services fast enough, according to a report.

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 last 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.

The health board, which runs the NHS in north Wales, apologised 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 last 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, whose mother Joyce died on the Tawel Fan ward in 2012, said: “These recommendations were supposed to be done a long time ago.

“The fact that we are here – in the worst case 10 years on – still discussing things that haven’t been done is extremely distressing.”

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

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.

Geoff Ryall-Harvey from the patients’ watchdog body Llais 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.”

The Welsh government said the health board had accepted the report’s key findings and it expected them to deliver those.

Betsi Cadwaladr Health Board boss, Carol 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.”