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.