Betsi health board: Damning reports after patients' deaths

The deaths of two patients have sparked damning reports into the failings of mental health services in north Wales.

They died at two separate units run by Betsi Cadwaladr health board - patient D killed herself and patient A died after suffering abdominal distress.

The reports flagged mixed cohort units, and observations not being carried out often enough which led to "catastrophic" outcomes.

Betsi Cadwaladr health board has apologised.

The first report said patient D took her own life at Hergest Unit, in Ysbyty Gwynedd hospital, on 20 April, 2021.

Staff had reduced her observations from every 10 minutes to every hour.

The report said this was not "appropriate based on the risk information available" and "is likely to have contributed to the likelihood and catastrophic outcome of this incident".

It added: "Staff could reasonably be expected to have intervened sooner in response to self-harm if D was subject to more frequent observations every 10 minutes."

The report also said "mixed cohorting", where frail, elderly patients are cared for on the same wards as younger patients, was a contributory factor.

The second report refers to patient A who died at Ty Llewelyn, Llanfairfechan, Conwy, after complaining of abdominal pain and discomfort.

Patient A slept from 22:00 BST on September 30 until 09:40 the following day, when nurses on the early shift opened the bedroom door to check on the patient.

"There is no evidence to suggest that any staff had a physical interaction with patient A in those 11 hours," the report said.

Nurses only observed the patient's position in bed.

This was despite the patient being pale, having a racing pulse rate and low oxygen levels, and there being a "strong aroma" coming from their bedroom.

"Unfortunately, these indicators were not recognised as warning signs of their physical health deteriorating, and was left undisturbed by staff for the remainder of the night," the report said.

The problem of mixed cohorts at the Hergest Unit was highlighted in the Holden Report back in 2013, but those findings were only made public in November 2021.

Geoff Ryall-Harvey, from the watchdog North Wales CHC, wants mental health services at Betsi put back into special measures.

He said: "There were failures around observation. There were failures to identify a risk of suicide. It is deeply distressing that someone so vulnerable could be placed in that situation.

"The issue of toxic mix has never really been addressed."

He added: "It also highlights issues around staff training. The young man who died was left unobserved for over 11 hours.

"I think special measures for mental health services would be justified. I think these reports show that there needs to be a level of intervention, and a level of monitoring, that the Welsh government need to be involved in."

Teresa Owen, Executive Director of Public Health and BCUHB's Mental Health and Learning Disabilities Division, said: "On behalf of the health board I want to reiterate how deeply sorry I am for the failures in their care and for the way we communicated with their loved ones.

"We are determined to leave no stone unturned in order to learn lessons from these tragic incidents. That is why we commissioned these external reports, which we have made public in line with our commitment to openness and transparency.

"We are determined to deliver further improvements, at pace, over the coming weeks and months."

A Welsh government spokesperson said: "Our sympathy is with all those affected by these two tragic deaths. Betsi Cadwaladr University Health Board has accepted the recommendations in these reports and we expect them to be implemented with urgency."

The Welsh Conservative's Darren Millar said: "These reports make for extremely distressing reading and my heart goes out to the loved ones of those who died as a result of yet more failings in the NHS in north Wales.

"We need an urgent and rapid plan of action from the Welsh government to hold those responsible for these failings to account and to resolve the problems in mental health care in the region once and for all."

Plaid Cymru's Llyr Gruffydd said: "Urgent action is needed to ensure nothing like this happens again.

"It's clear that taking mental health services out of special measures was a mistake and the minister who made the decision should apologise to the families."