Tawel Fan ward, an older people’s mental health ward in the Ablett Unit at Ysbyty Glan Clwyd in Bodelwyddan was closed in December 2013 following concerns being raised about the quality and safety of care provided on the ward.
The Health Board had undertaken internal investigations resulting in some staff being removed from clinical duties. As a consequence, patients were transferred to other care settings. The ward has remained closed since.
In January 2014 the Health Board commissioned an independent external reviewer, Donna Ockenden, to look at patient care on the ward. The Board were updated on progress in July 2014. In September 2014, the Ockenden report was finalised and was immediately shared with the North Wales Police who confirmed that they would formally investigate. In May 2015, the police advised that no criminal charges were to be brought.
During this period, the Mental Health management team were stood down in the autumn of 2014 and an experienced Interim Director of Mental Health and Learning Disabilities was appointed to provide leadership to the division, which runs inpatient and community services across North Wales.
The Ockenden report was published in May 2015 and attracted intense media interest. The report provided a view of care on the ward, drawing on information from 40 members of staff and 15 family members. The report concluded that there was a culture on the ward that resulted in institutional abuse. The report was accepted by the Health Board, who determined that Ockenden’s findings warranted further investigation to achieve a full picture of the care provided on the ward prior to its closure.
In June 2015, the Health Board was placed in Special Measures by Welsh Government and mental health services were one of the areas identified as requiring significant improvement.
In September 2015, the Health Board commissioned an independent comprehensive investigation from HASCAS.
The Health Board commenced a thematic mortality review into all deaths on the Tawel Fan Ward during 2013/14 to identify any improvement areas. A mortality review is not an investigation, but a clinical review to identify where care and treatment can be improved. This report was drafted but never finalised or formally received/approved, and the independent reviews mentioned above were commissioned and took precedence. In the spirit of openness and transparency, we have published a redacted version of the thematic mortality review. The redactions made include the removal of individual names and other identifying information in accordance with data protection laws.
Review Of Deaths Associated with Tawel Fan Ward, Ablett Unit, BCUHB - February 2015 Deaths
BCUHB Media Statement, 12.07.18
Donna Ockenden Press Release, 12.07.18