I call on Llyr Gruffydd to speak to the topic he has chosen. Llyr Gruffydd to begin, once the Chamber is quiet. Llyr Gruffydd.

Thank you very much, Llywydd. It's my pleasure to introduce this short debate this afternoon on the subject of the Holden report on mental health services in north Wales. I've agreed to give a minute of my time, first of all, to Rhun ap Iorwerth, and then Mark Isherwood, and then Darren Millar, and then Mabon ap Gwynfor.

Mental health services present one of the greatest challenges for our NHS, and sadly it is a growing challenge. That's why it's important that we learn lessons from previous experiences and that we're honest in acknowledging mistakes and failures when they occur. Mental health services in north Wales, of course, were identified as one reason why Betsi Cadwaladr health board needed to be taken into special measures, more than six years ago, by the then health Minister—now, of course, Wales's First Minister. That was a clear statement and an acknowledgement of previous failings and mistakes, and in that respect the move was to be applauded, even though, of course, it might have been inevitable, but it was certainly very disappointing. But what concerns me now is that, six years on, we're not seeing progress in this sector. Instead, I fear, we're seeing a culture of cover up and a refusal to accept responsibility at the very highest level of both Government and the health board. The focus of this debate is the failure to date to release the Holden report by the health board, and that, I feel, is symptomatic of a wider problem.

The report was compiled back in 2013, after dozens of health workers came forward to blow the whistle on poor practice at the Hergest mental health unit in Bangor. Their testimony amounted to 700 pages of damning evidence that mental health patients were not getting the treatment they needed and that they deserved. In addition, vulnerable elderly patients with mental health issues were being placed side by side with drug addicts and people with other severe needs, in a wholly inappropriate way. Staff were unable to complete Datix forms—the internal forms for reporting problems—because of time constraints, so the problems were being allowed to fester by senior management. It was a recipe for disaster, and of course that disaster ultimately involved patients taking their own lives because ligature risks that shouldn't have been there were there.

You would imagine that a report into this kind of problem would be able to identify solutions and responsibility. I'm hoping it did, but of course I can't be sure because the report has never seen the light of day. To this day, Betsi Cadwaladr health board is refusing, despite requests, and, more recently, demands from the Information Commissioner's Office to release the report. To my knowledge, not one manager has been directly disciplined, although last week it was revealed that two managers were moved. This failure to take accountability for any failings has been a symptom of this whole sorry affair. And instead of demanding managers take responsibility, what we've seen, of course, is that whistleblowers have been scapegoated. Crucially, the same risks that sparked the Holden report eight years ago have not been eliminated from the unit, and this has consequences—serious consequences.

Earlier this year, a woman from Caernarfon took her own life on the unit, and she was able to do so because the same ligature risks that were present a decade ago had not been eliminated, despite being identified in the Holden report. This would be an internal health board issue were it not for two things, and this is why it is important that this issue is raised in this debate in this Senedd this evening. Firstly, as I mentioned, mental health services in north Wales were already a subject of sufficient concern six years ago for that to be cited as one of the reasons for the Welsh Government to take the health board into special measures. So, the Government was aware that there were problems. More specifically, last year, the then Deputy Minister for mental health, the now Minister for health, who will be responding to this debate today, gave me assurances in this Chamber that she would read the report and give the matter her attention. 

On 4 November last year, in this Chamber, Minister, in response to a question from me, you said that you hoped that I would give you some time to look at the report and understand more about the background. I quote you—your words were, 

'I will look at the Holden report and see exactly what the situation is here.'

Those were your words on 4 November. Since that pledge, nearly a year ago now, we've had nothing further from the Minister and nothing further from the Welsh Government. But what we do know, of course, is that deaths are still happening on the mental health units in north Wales and that the number of serious incidents and patients coming to harm have increased year after year. Twenty-five cases in these last three years alone. Each one a scandal, each one a tragedy, and many of them, I'm sure, could have been avoided, while your Government is sitting on its hands on this issue. 

So, you told us in the Chamber that you would read the report, and I've no reason to doubt whether that has happened, but now, Minister, this evening, you need to explain to us, firstly, why the Holden report has still not been made public; secondly, why the recommendations of the report have not been carried out; and, thirdly, you need to explain why people are still dying on mental health units in north Wales when those risks should have been eliminated.

This is a tragic, avoidable scandal. It's a scandal because nobody has been held to account for these failings. And these aren't the failings of overstretched front-line staff. These are the long-term failings of senior managers who have continued to be employed by the health board, some of whom have very senior roles in Betsi Cadwaladr. It was avoidable because staff, families and Holden had raised the alarm many, many years ago. And the tragedy is that no action was taken, or that not sufficient action, at least, has been taken to date, and that means that vulnerable people are still dying on mental health units in north Wales. And I use the plural, because, in the past year, we've seen deaths on Hergest and also on the Ablett unit in north Wales. 

We've seen glacial progress in terms of getting the facts out into the open, and it's time this Government showed some leadership, and it's time you held your hands up to Holden. Let's have this report out in the open so that we can all see for ourselves what needed doing back then, and what needs doing now, so that we can start to deliver the mental health services that the people of north Wales deserve. 

I thank Llyr for bringing this issue before us today and, indeed, for his work in this area over a period of years. Let me speak quite openly: the Betsi Cadwaladr health board is still facing very grave problems with its mental health services. The Hergest unit is still facing very serious questions around patient safety. And, yes, it was too soon to bring the board out of special measures. Despite the efforts of staff to blow the whistle in order to bring about improvements, despite campaigns from patients and families, we, once again, over the last few weeks, have been talking about loss of life in Hergest and about fundamental questions on the circumstances. Robin Holden listened to staff who wanted to voice their concerns, but I can't overemphasise the damage that's been done, and the doubts confirmed, as the board fails to publish the report and fails to be seen to be transparent.  

We're talking about serious, deep-rooted issues affecting patient safety, resulting in tragic losses of life. We're also talking about impacts on hard-working front-line staff, desperately worried about the care they can offer due to problems with underinvestment and under-resourcing. Responsibility, finally, must be accepted and acted upon for the years of failings in mental health care in north Wales. The debate today focuses on how releasing the Robin Holden report is surely a vital step towards addressing the wider problems and getting to the root causes of these tragic problems once and for all.

Four years after I first raised concerns with the Welsh Government, the 2013 Holden report, commissioned after patient deaths and complaints by 42 staff, warned that the Hergest psychiatric unit at Ysbyty Gwynedd was in serious trouble. I understand that Betsi Cadwaladr University Health Board asked staff criticised in Holden for putting lives at risk to write the paper to the board. After Betsi Cadwaladr University Health Board refused to disclose the full report, the Information Commissioner's Office ruled that the health board should disclose a full copy with only the names of individuals subject to the grievances redacted. However, the North Wales Safeguarding Adults Board say that they can't take any action because of an absence of specific details and information. 

We must not allow this to be dismissed as ancient history. As we heard, two patients in north Wales mental health units have died from hangings and attempted hanging over the last year alone. Families identify a categoric failure of the regulatory framework by all statutory bodies to react to Holden. The onus is now on the Welsh Government to ensure transparency and to show that it is not complicit in a cover-up.

I'm very disheartened to know that we have a Welsh Government here that has failed to intervene so far to ensure that the antiseptic of sunlight can be spread abroad on the particular report—the Holden report—that we're discussing. We know that there are deep-seated problems in our mental health services in north Wales, and I want to ask the Minister, along with the chorus of voices that have already spoken, and the further speakers to speak: how many more people have to die? How many more vulnerable people need to suffer harm unnecessarily? How many more families need to lose their loved ones before we will see the radical action that is necessary in order to resolve the fundamental problems that we still have in our mental health services in north Wales some six years after they were identified as failings sufficiently to the extent that the health board was put into special measures? It simply isn't good enough. And we look to you, as a new health Minister, to step up to the plate, to hold people who were responsible for these failings to account in order that we can get some justice for those families who've lost their loved ones and those patients who've been so tragically let down.

Thank you very much, Llyr, for bringing this debate before us today. I want to start my contribution by paying tribute to a constituent of mine in Dwyfor Meirionnydd, David Graves—the son of the late Jean Graves, who died in June 2016. David has been very determined in his campaign for a number of years in trying to ensure that this report is released fully. Jean was admitted to the Hergest unit because of her mental ill health. She had early onset dementia. Unfortunately, she also suffered in Hergest. Her care needs as an older woman with mental ill health were very different from those of other residents who were younger, some with drug problems. Unfortunately, it wasn't just Jean who suffered in Hergest, and the fact that there are ligature points still in units where patients are at risk of suicide show that the lessons have not been learned. And that comes as no surprise, because there has been a deliberate campaign to try to conceal the Holden report. Someone has to take responsibility for the terrible failures that emerged from Holden and, indeed, Ockenden. But, more than that, if we are to have confidence in our mental health services once again and learn the lessons fully, then we have to see that report being published in its entirety. Thank you.

I now call on the Minister for health to reply to the debate.

Diolch, Llywydd. Thanks for the opportunity to respond to this debate and to put on record my recognition of the commitment of the Betsi Cadwaladr health board to continue to improve mental health services.

Now, whilst both I and the Deputy Minister for Mental Health and Well-being are challenging the health board to increase the pace of change in relation to mental health services—and both of us have brought this up with the health board on several occasions—I do recognise the impact that this level of scrutiny over so many years will have on staff morale. At the outset, I want to say on record that I recognise the efforts of all the staff at the health board and appreciate the work that they do.

In 2013, Robin Holden was commissioned by Betsi Cadwaladr health board to undertake a review of the Hergest psychiatric unit following complaints by staff, and I am familiar with the content of the report, and I must say it does make uncomfortable reading. Now, the call for the publication of the full, unredacted version of the Holden report is a matter for the health board, and some will be aware that there is currently a live case with the Information Commissioner’s Office. It’s therefore not appropriate for me to comment on this particular aspect in the debate. What I can say is that I expect the health board to fulfil its statutory obligations to both the people of north Wales, in terms of openness and transparency, and also, importantly, to its staff, by protecting the anonymity of people who raise concerns. The health board must also, of course, ensure it meets its legal obligation around data protection.

It’s always important to note that, following the review, a summary report was published by the health board in 2015, which included the recommendations made by Robin Holden. The executive medical director and executive director of nursing and midwifery subsequently commissioned a piece of work to ensure that the Holden report’s recommendations have been implemented, and this work was submitted for executive scrutiny and was reported to the health board’s quality, safety and experience committee in January 2021. Now, this provided assurance that action was taken and remains in place against each of the recommendations of the report, and my focus now is on ensuring the health board continues to act on those recommendations.

Now, as we’re all aware, the Holden report was one of a number of independent reviews commissioned by the health board in response to concerns about the quality of mental health care in north Wales in recent years, and which led to its placement in special measures in 2016. Now, since that time, much has happened, and the health board made progress against the milestones set out in the special measures framework, particularly including improved governance and quality, and improvements in mental health services. However, I am clear that there is still a long way to go, and that’s why the health board remains in targeted intervention. We must remember that targeted intervention is a high level of intervention with ongoing scrutiny by Welsh Government that recognises that the health board remains on an improvement journey. A new chief executive has been appointed to steer the health board on its improvement journey, and it’s clear that there is much greater oversight and scrutiny of mental health services now at board level.

In mental health, a part of the organisation that was subject to continuous staff changes, I’m pleased to say, has now been stabilised, and that stability at a management level has started to increase confidence in the service to deliver. Improvements to organisational and governance structures have been put in place with a systematic way of identifying and reporting issues as they arrive. These same improvements also allow changes to be implemented more efficiently and effectively. Innovative working that used to be seen in isolated pockets is now being spread much wider, and there is clear evidence of much greater integration among services. For instance, child and adolescent mental health services that were previously run as three different and unconnected sub-regional services have been brought together, enabling best practices to be retained across the whole service and allowing a more integrated and cohesive service. And there’s now much greater alignment between adult mental health services in the health board and those in place to support children and young people.

There's also a much stronger strategic overview of the three regional areas, which is so important in a large geographical area such as Betsi Cadwaladr. The 'I CAN' initiative is another good example of innovative improvements to mental health services, providing easy access to support and offering an alternative to admission to hospital. The health board has now relaunched its 'Together for Mental Health' strategy for north Wales, which is resulting in much stronger partnership working with local authority and third sector partners across the region—so, essential to support the preventative and early intervention part of mental health.

In line with the targeted intervention framework issued to the health board in February, the board has signed off the four maturity matrices and baseline assessment for mental health at its board meeting on 20 May. Now, the matrices are very detailed, and I intend them to be dynamic documents that are regularly reviewed and updated, and they focus on areas for improvement. They are owned by the health board, developed with the staff on the ground who've shown real insights into the difficulties they face and the challenge ahead of them. So, there are many key deliverables, and I'm happy to write to Members who request for me to set those out.

Now, I'm pleased to say that officials are meeting regularly with the health board to review progress against the matrices, and I welcome the transparency and openness being demonstrated by the health board as part of this process. The board has also been very realistic, and in its own assessment has recognised that there's much work to do. And whilst I recognise that the baseline scores are low, they reflect an honest appraisal of the position the health board is in. It's important to note that these scores are not reflective of the whole area, but of those areas that are in targeted intervention. They set a strong baseline against which we can track progress through the four maturity matrices. Recovery and transformation will take time, but we've consistently made it clear to the health board that being able to evidence service improvements is the key to progressing across the matrices with a view to further de-escalation.

And just last week, there was a mental health round-table discussion, chaired by the NHS Wales chief executive, which also included the chair and chief executive of the health board and senior mental health service leads. The purpose of the round-table, which also included Audit Wales, HIW and Welsh Government officials, was to open a frank and open discussion of the LHB's previous position, to assess the current situation and to provide assurances that the right mechanisms are now in place to secure improvements to mental health services in north Wales. And I'm reassured that there was wide agreement, following that meeting, about the openness and transparency being shown by the health board.

But I also want to acknowledge the recent and tragic incidents at the health board, and I can assure Members that these incidents have been formally reported, as part of the NHS Wales national incident reporting policy, and are being investigated. I expect the health board to undertake a timely review to ensure immediate safety issues are identified and actioned, and to reduce the risk to patient harm. Processes should support a just culture for organisations and staff to feel supported to identify, report and learn from patient safety incidences.

The Welsh Government continues to monitor and, importantly, to support the health board. There are regular meetings linked to the formal targeted intervention process between officials and the health board, as well as regular performance and quality and safety discussions. These are rooted in robust challenge, but we'll also consider what further support we can offer as a Government. It's clear that there is a real desire to deliver change and secure improvement, and we all owe it to the people of north Wales to support the health board to deliver for them. Diolch, Llywydd.

Thank you, Minister. That brings today's proceedings to a close.

The meeting ended at 18:19.