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.