Part of 4. Topical Questions – in the Senedd at 3:34 pm on 30 January 2019.
I agree with a fair amount of what Dai Lloyd has said about this being a matter of real seriousness and gravity. It is a serious issue. That is why I ordered the inquiry, with the report that we've published. And, if you look at the report, there's no hiding place in the report. It sets out a range of areas where there is a need for real improvement. It sets out a range of failings and disappointments about past conduct. And that is important to have an honest picture to improve upon. But, actually, in terms of learning disability, I recognise what Dai Lloyd says about differential mortality. That is not a cause for celebration, it is a cause for not just for concern, but for action. That is why the Government has, of its own volition, undertaken a review across Government in terms of learning disability services, which I, Rebecca Evans in a previous role, but also Huw Irranca-Davies in a previous role as well, have been actually part of undertaking and reviewing and taking forward, because we do recognise we need to do better. We recognise there are real challenges and a need for improvement. There's no lack of understanding or commitment from the Government to do better. If you want to see examples, there's real leadership from the chief nursing officer as well on this issue. She has made it a real priority within the last few years, because of the mounting evidence about differential outcomes and the failure to make appropriate progress.
For example, earlier this term, I met the family of Paul Ridd to look at what had happened with his care, where, again, he was let down, and the family then came back, after a period of time—we quite understand that they were angry and did not want to come back. They then decided they wanted to do something to make sure others did not go through the same experience. And that has actually been a really positive experience for this health board as well. The learning they have taken on board for matters on the ward—and, indeed, Melanie Thomas, one of the nurses they have dealt with, the learning disability co-ordinator, was actually recognised for her work on learning disability within the recent new year's honours list.
So, there is good practice within Wales. As ever, the challenge is how consistent is that and that the learning isn't simply kept in one part of our service. So, I do recognise that there have been failings. I want to be clear that the Welsh Government does not authorise a desktop review as the only response that should take place. The health board undertook a desktop review, and, following that, I was not satisfied that was the appropriate course of action, that the learning had actually been deep enough or, indeed, that they'd learnt all the lessons and asked all the right people. So, I ordered Healthcare Inspectorate Wales to undertake a review.
In terms of the treatment of the whistleblower, well, the challenge here is that Healthcare Inspectorate Wales went through that. I would always want whistleblowers to be believed, and I would want—. Again, you start off by believing the whistleblower and taking what they say seriously if you want the right culture to take place. I certainly do believe there's more learning to take place and it's been raised directly with me by the British Medical Association. I think we will be in a better place but, as ever, we will continue to learn from where we get things wrong as well as where we get things right. There is much that we should not be proud of here, but also I think what is most important is the commitment to do better in the future.