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.