We now move to the short debate, and I call on Bethan Jenkins—[Interruption.] If you’re leaving the Chamber, will you do so quickly and quietly, please? If not, please sit down. Thank you. Sorry, Bethan. I now call on Bethan Jenkins to speak on the subject that she has chosen. Bethan.

Thanks. I’ve given a minute to Angela Burns.

When approaching this debate, thinking about the issues it poses, including patient rights, how we support and trust victims of crimes or mistreatment in the NHS, how we safeguard against future incidents, and how the NHS handles problems and major incidents when they do arise, I felt it was important to use current events as a prism through which to look at these problems.

The Kris Wade case is of course one that people will know here I have taken a particular interest in, not just because Abertawe Bro Morgannwg University Local Health Board is in my region, but I’ve taken an interest because the case has demonstrated clearly, despite the review and the promises and assurances, Wales is still in a situation where a major health board has failed again to properly live up to the expectations people have of their NHS, and, more fundamentally, women have been failed—victims of sexual abuse—by having a sexual predator in an alleged safe environment.

I must put this case on the record, have a proper discussion about it, and assess what went wrong and the issues that have arisen as a result. The ‘Desktop Review Lessons Learned Report’, published by ABMU in August, was something of a contradiction in terms. I think we would agree that, in order for a proper review into a major incident to be thorough, and to demonstrate that lessons have in fact been learned, such a review would acknowledge the gravity of a situation such as the one under discussion before anything else. But, in fact, what we saw was something quite different. The report itself was inexplicably late. We were informed initially that the review would be ready in January. It was not published until August. No explanation has been given for this. The review being led by the former chief executive, Paul Roberts, did not materialise, and instead a desktop review was published with redacted authors—a far cry from the thorough and wide-ranging process that was expected and deserved. I have been told that repeated requests by a consultant and former clinical director to give evidence to the desktop review were repeatedly denied. The report came to conclusions for which there was absolutely no basis, such as the claim that there was no link between the failure to prosecute or dismiss Mr Wade and his murder of Christine James. This is something that, unfortunately, others, including the Welsh Government, have repeated. How can this claim conclusively be made when Mr Wade clearly committed a series of sexual assaults against vulnerable women, aggressive actions that are often recognised as precursor behaviours to more serious crimes? In the opinions of many, including some legal opinions, there is a causal link between declining to prosecute and the fact that Mr Wade faced no legal issues at the time he committed the murder of Christine James.

There was scant information over how Mr Wade came to be employed as a health support worker, working with vulnerable people, in the first place. Mr Wade started with the predecessor authority, Bro Morgannwg, as an information technology technician. He was also not subject to any advanced Criminal Records Bureau checks, which is a requirement for the role he was later employed in, and shockingly, ABMU have told my staff, and the staff of other AMs, that they still have outstanding CRB checks to do on current staff.

The report skirts around any potential conflicts of interest of nepotism within management of ABMU. It simply says the point is neither here nor there. It failed to draw conclusions one way or another. This did not strike me as good enough at the time, and it is an aspect of this that deserves greater attention. Kris Wade was, after all, employed as a health support worker in the learning disabilities service without the mandated checks, when his father, Steven Wade, had been the clinical director responsible for the service. One of the most critical parts of this case, and one which is barely reflected upon at all in the review, was why Mr Wade was not dismissed sooner than he was. Why were there so many delays and disciplinary hearings over his actions when there were allegations from three people? Responsibility for this does lie directly at the door of ABMU, and there is a clear responsibility to be taken and lessons understood in terms of safeguarding as we move forward.

Although it’s shocking, there is a recognised risk within the NHS of vulnerable people, particularly women, being abused. In fact, Rowan House stands on the site of Ely Hospital, at which the inquiry into failures of patient care for people with learning disabilities took place in 1969. The Kris Wade case occurred under the health board in which standards of care at Princess of Wales Hospital had been subject to the independent inquiry and subsequent Andrews report, ‘Trusted to care’, and similar incidents had occurred within its mental health services. ABMU has acknowledged its failures of care towards people with a learning disability in the tragic case of Paul Ridd. Even without the local examples, the failures and abuse witnessed in other health boards across the UK and in care facilities should have been a clear warning to the health board to take allegations of this nature seriously, that, in cases of this kind, employment has to be weighed against risk, and there was a clear risk and a pattern developing with this case.

Also omitted from the review were the problems with governance at ABMU. A former consultant from ABMU who I met told me, ‘I had personally raised concerns with the medical director in 2012 following the second allegations of abuse and its implications recognised. Concerns around the internal governance and leadership of the director were highlighted in internal reviews of governance and performance, but not acted upon. And a comprehensive range of concerns raised by myself and others about the failures of governance and actions of the clinical director were either ignored or, more actively, suppressed by the executive of the health board.’ There are clearly major accusations to make here, and those weren’t raised in the lessons learned report, in no small part because his requests to submit evidence were rejected. He goes on to say, ‘The culture within ABMU health board left the clinical director a free rein to run, without proper oversight, an isolated service which operated without accepted governance practices.’ This cannot be acceptable.

Clearly, despite it not being part of the desktop review, governance at the health board is a key issue here. There has been no clear accountability or responsibility from management over what happened and no formal apology. The victims of Kris Wade had to find out from the television that the desktop report had even been released. This is abysmal behaviour on behalf of ABMU. The British Medical Association recently said that the health board should not be allowed to review themselves, and I think Angela Burns has said something similar, and I quote,

‘The Francis Report starkly portrayed the catastrophic effects when concerns are not dealt with effectively, and post Francis, we believe it is unacceptable for a health board to investigate serious concerns about itself.’

It becomes crystal clear from this case, and from the desktop review, that there needs to be a better and more robust framework in place to oversee the management of health boards. If a doctor made a serious mistake or a number of them, then there are professional disciplinary bodies that would have the authority to deal with any of these cases, but no such body exists in the case of managerial breakdowns of responsibility. The boards can’t keep getting away with this. They must be held to account. While we can never say for certain that what happened in the Kris Wade case will never happen again, there are, sadly, likely to be allegations of abuse and crimes committed against patients in future. So, we must prepare health boards and the NHS to deal with incidents more effectively and more timely than what has become apparent in recent events.

The police, I believe, must bear some responsibility in terms of what happened in the Kris Wade case. This is not a matter for the Cabinet Secretary, but there should be in the upcoming Healthcare Inspectorate Wales assessment a thorough as possible investigation into why the police did not bring charges initially in relation to the first allegation, and why the CPS did not bring charges with regard to a later allegation. There’s also a question to answer as to why, in one of the allegations, the police recorded that a crime had been committed, yet no charges were brought in relation to it.

Alan Collins, a solicitor representing one of the victims in the Wade case, told me this: ‘Police inaction is a concern in itself. I do not necessarily criticise the police, because none of us actually know why Wade was not prosecuted for the three sexual assaults, and that is because the information is not in the public domain.’ Moreover, the review authors were in the dark too. The fact is that three vulnerable patients were sexually assaulted by a man who posed a serious risk to women. He went on and killed. The public are entitled to know why this man was not prosecuted for the three assaults. Clearly, on the face of it, the police thought that crimes had been committed. The victims and the public are entitled to know why this dangerous man—because that is what he was—was employed in public service and not prosecuted. We are also entitled to ask: are there lessons to be learned from what we do know? Would, for example, the police approach these cases differently if reported today?

I would hope that you would support me in calling for HIW to thoroughly investigate this police matter, and that they give their full co-operation. The HIW report will of course be pivotal, and it will stand as a test as to whether or not we can have faith in the review and the oversight processes we currently have. I have met with HIW, and I was reassured, to an extent, that the case will be looked at in its entirety. However, to what extent witnesses and evidence can be compelled from outside the health board, or from those no longer employed by the NHS, remains a grey area, and I would leave open the option of calling for a full independent inquiry, under the Inquiries Act 2005, in future if necessary.

More broadly, I would hope to see a proper and humble apology from health boards after these events. I would hope that HIW will fully investigate health board management structures and how they work across Wales, in particular, accountability and who takes responsibility when clearly there is an incident to be responsible for; how health boards cope with major incidents; and what happens if safeguarding procedures are not followed or have failed. There need to be inquiries made regarding how we have better oversight of NHS management structures, recognising that it isn’t only doctors who make decisions that have a real and lasting impact on a patient or NHS user.

For me, one of the bigger negatives, which has emerged as a result of this case, is that there is clearly a culture of secrecy in some parts of the NHS where a light needs to be shone. There is an unfortunate tendency in some sections of the NHS, where the reaction to a major incident, or a number of them, is to put up the barricades and hunker down, rather than to open doors and resolve to openly and transparently find out what went wrong. I would hope HIW and the Welsh Government work together diligently moving forward to solve these problems once and for all.

I’d like to end with a quote from a consultant from ABMU, who told me, and I quote: ‘The lessons to be learned are ones of relevance not just to ABMU, but all other health boards. In brief, lessons cannot be learned if the Welsh NHS refuses to take the class.’ I hope, moving forward, that this isn’t the case and that the victims and their families get the justice they deserve. Diolch yn fawr iawn.

I’d like to thank Bethan Jenkins for bringing forward this debate on safeguarding and patients’ rights in the Welsh NHS. And the reason why I wanted to make a contribution was that, in January 2012, I did a short debate that was entitled ‘Does the Welsh Government have a moral responsibility to seek to protect whistle blowers in all walks of life?’ Because one of the incidents—and you talked specifically about the Kris Wade case—is that there were people there who were trying to blow the whistle, and they couldn’t and didn’t. The question is: why?

When I raised this before, the Minister who responded to me at the time, who is the current leader of the house, assured us that there is written guidance issued by Welsh Government to NHS trusts requiring each to develop its own whistleblowing policy and that a structured assessment of NHS bodies had been undertaken by the Wales Audit Office, which sought high-level assurances that whistleblowing policies and guidance to staff were in place. The reason I feel so strongly about this is that, in this instance, whistleblowing didn’t work. In Powys, which we talked about earlier, people tried to whistleblow, and that didn’t work. And currently, I’m being ticked off by a major health board because somebody has tried to whistleblow, got slapped down by the health board, who then came to me, and I’ve raised those concerns. I’ve got a letter—which I will share, I won’t publicly shame them, but I’m happy to share it with you, Minister—that basically tells me that because they haven’t gone through the policy, the procedure, then tough luck. The reason people can’t whistleblow is because they are frightened. The reason they don’t whistleblow is they are scared they’re going to lose their jobs or their lives are going to be made an absolute misery. And, when good people walk on by and do nothing, it allows things like the Kris Wade incident to get away, to happen without having proper punishment.

We must start having a robust system in place that everybody in the NHS and other public service bodies absolutely cleave to in terms of being able to point out something that they feel is morally or factually incorrect, and have a manager who is outside of that system, looking at it and examining it, and above all somebody—and I know I’m just discounting all the malicious people, and there aren’t that many of them—

And you’re going to wind up now, because you’ve gone well over your minute.

Sorry.

No, no, it’s fine.

But, these people should have that right, because without them to act as a check and balance on our public services, we will have more of these awful, appalling instances in the future.

Thank you. I call on the Cabinet Secretary for Health, Well-being and Sport to reply to the debate. Vaughan Gething.

Thank you, Deputy Presiding Officer. I’d like to thank both Members for their contributions in today’s debate, which is of course a significant and generally serious issue for all Members in all parties and all of the constituents that we are here to serve.

I think there is genuine cross-party support for ensuring that all patients using our services receive safe, high-quality care and are protected from harm. Much of what we discuss is where that doesn’t happen, in this place. It is of course the nature of our business that we’re less likely to talk about things when things go right, but actually to talk about the things that have gone wrong and to try to understand why.

For patients, that’s why we’ve put in place the Putting Things Right process, to integrate those, to try and ensure that those issues are investigated and addressed. We do want to see a single, integrated approach to make it easier for people to raise concerns and to provide a fair outcome for individuals and is consistent in the way that people are treated. In doing so, we expect to make the best use of our time and resources, and to make sure that people really do learn lessons from where things go wrong.

Concerns and complaints could and should be raised by patients, staff and members of the public, and all who raise them should receive support during the process. I recognise that, whatever the process we have in place, there is always an element of human error to fall within that. Within NHS Wales, staff should be treated with dignity and respect, in line with our established policies. All NHS organisations, as employers, must take action to address any concerns raised by staff in a prompt and timely manner. There is an all-Wales procedure for NHS staff to raise concerns, as agreed in partnership with the Welsh partnership forum, and that’s reviewed on a regular basis to ensure it is fit for purpose.

I shouldn’t respond directly to some of the points that Angela Burns has raised because in my previous life, when I was an employment lawyer, there’s the challenge of the rights that people have in theory and in law and actually the really difficult part of how you assert those rights in practice. Because even in an organisation like the NHS, and it’s a privilege to stand up and to be a Minister for the health service, but within the 76,000-odd staff, we reckon there is imperfection. There are times when people make mistakes and there are times when people don’t just make mistakes, but actually it’s a rather more deliberate approach. That isn’t to attack the service; it’s to recognise, in a human service, that will happen.

Our real challenge is how we support people in practice, because we ask people to raise their heads above the parapet, and that is not always easy. I’m always interested to understand when somebody raises a concern or complaint, it may not always be something where there is a full investigation, but they should not suffer a detriment from doing so. That is a challenge about the cultural part and the vision and the values. That’s why we did lots of work with the BMA on the vision and values for the service, and that’s still as relevant now as it was when we actually introduced and agreed that work.

For children and vulnerable adults, the NHS has been actively improving its approaches in recent years. The national safeguarding team works across NHS Wales with stakeholders and partners to help local delivery in health boards, as well of course as our regional safeguarding children and adults boards, where designated professionals provide a source of independent, expert health advice from an all-Wales perspective. In addition, there is an NHS Wales safeguarding network that connects organisations across NHS Wales to try and create that collaborative environment to recognise common issues, develop solutions, and achieve healthcare standards that better safeguard the welfare of children and adults at risk. At its heart is the evaluation of the efficiency and efficacy of child protection and adult safeguarding arrangements and interventions, as well as trying to reduce the variation in practice within the NHS. Examples of what the network has done already are the NHS Wales quality outcomes framework for safeguarding children, the child sexual exploitation prevention strategy and action plan for NHS Wales, and quality standards for medical advisers’ roles in adoption and fostering, and we also have the all-Wales female genital mutilation clinical pathway, thinking about the range of areas where people come forward into our service. And, of course, a key part of the Social Services and Well-being (Wales) Act 2014, passed in the last term of the Assembly, was the establishment of a new national independent safeguarding board, which is now chaired by Dr Margaret Flynn. And their job as a board is to advise Welsh Ministers on the adequacy and effectiveness of safeguarding arrangements across Wales. We’ll never be in a position, I think, where we can say that everything is perfect. There will always be a need to review our procedures and our practices, to understand whether we have the best possible system in place, and, equally, whether we have people in place to do so.

I’ll come on to the points that Bethan Jenkins in particular mentioned about the individual case in point. And there’s not just a challenge about whistleblowing, but, in this particular case, with the three previous allegations, unfortunately it appears to be the case that those complainants were not seen as being reliable. And that’s a real problem for us in our system. It should not be the case that vulnerable people, whether children or adults, are seen as intrinsically unreliable. And that is a problem. The health board did, though, refer those allegations promptly to the criminal justice system. The police investigated. And, on each of those occasions, the criminal justice system decided not to proceed. That is a problem for us to understand. But, in the Healthcare Inspectorate Wales review, they don’t have the powers to go into and investigate what the criminal justice system did. What we do need to assure ourselves of, with our responsibilities, is that, the action that was taken, what lessons are there to learn, and look to the future about what more needs to be learned for others. There will be people in our service, sadly, who are in a position where they have not behaved as we would have wished them to around people in their care. That is something on which we do need to have the independence of the HIW review, but I, of course, expect them to have a conversation with the criminal justice system about what happened in this case, and there is definitely learning for the criminal justice system from the Kris Wade case as well.

But I depart company with Bethan Jenkins and a number of others on the very stark view that health boards should not investigate serious concerns. I think health boards have to investigate serious concerns where they have responsibility. There will always be a challenge about when is it appropriate, then, to have an independent review in addition, because we expect the health boards to look at serious concerns, and they already do. We regularly have ombudsmen’s reports, where they actually look at what the health board has done, and, in some of those, they don’t always get it right. They still need this process about understanding what they’ve done, and properly learning and improving. And, in this case, we’ve decided that there should be an independent review, which is why we’ve charged HIW to undertake that review.

Will you take an intervention?

I will take an intervention.

On this particular report, however, the authors were redacted. We’re having an internal review and we don’t know who actually wrote it. So, it’s very hard to have faith in a system where we can’t properly scrutinise it, and where that actual report did not take evidence from those who wanted to give evidence. How can you be assured that that will happen, if health boards investigate themselves?

I understand that points have been raised about people and where the evidence was taken, because it was a desktop review. My understanding also is, before finalising that report, there was a conversation with one of the people who was a whistleblower. But we’ll get through that with the HIW review, and, if there’s a need to look at our process again, with the learning that will come from this, we will want to learn that. That’s the point about being open and accepting—that we don’t start the HIW review from the point that this is about defending the service. It’s actually about understanding what’s happened, and understanding what we could and should do differently in the future.

There are of course a range of serious allegations made today in opening this debate, and the statement about Kris Wade having clearly committed a series of sexual assaults. I am not in a position to say whether that is the case. That’s part of the challenge about the interaction with the criminal justice system, and their opportunity to investigate that and to understand what has happened. The HIW review will look at the range of issues through the whole process. I’m interested in the delay in resolving the employment issues after suspension. I’m interested in what’s the interaction between different representatives—is there a good excuse, is there not—and to understand what more could and should we do. Because, occasionally, when you have lengthy suspensions, it’s not good for the organisation, it’s not good for the individuals, or the people all around that potentially as witnesses.

We’ve discussed the Kris Wade case previously. I’m sure we will do again. I just want to make clear that, in response to some of the other points that were raised in other challenges around this health board, I think the Paul Ridd failing of care is a really interesting example of where, having been criticised, having had a serious adverse finding made against it, the family re-engaged with the health board to want to try and improve the situation. It’s a mark of the fact that the nurse of the year this year is in the learning disability service within the health board. Lots of her work in terms of the award she’s got is because she’s engaged with that family and listened to them and they’ve changed the way they behave within that health board, in particular around people with learning disabilities. That’s an example of the openness we want to encourage. We, of course, ideally, want to have a system where we remove the opportunity for failures to take place in the first place, but it’s really important that we do take the opportunity to learn and then to act after that to improve the quality of healthcare that all of us expect, not only for ourselves, but for all the people who we represent.

Thanks very much, and that brings today’s proceedings to a close.

The meeting ended at 18:51.