Speaking here in September, the health Minister said it was important to note that a summary report was published in 2015, including the Holden recommendations. But this is the very brief summary report referred to above, which did not describe the 31 concerns listed by staff. Throughout my time as a Member of the Senedd, since 2003, I have supported a succession of principled whistleblowers who have been threatened, bullied, denigrated or damaged for daring to tell the truth in Wales. An event that led directly to Holden involved two senior nursing staff who had raised safety concerns being summarily marched out of the building on a trumped-up basis. In the case of Tawel Fan, two members of the medical staff were put on restricted duties and referred to the General Medical Council. One of them had raised safety concerns with management, but was told that doing so indicated he was not a team player.

A letter I received from Professor Healy in 2019 stated, 'Several of my patients have died, in part because of difficulties in getting them input. I wrote to the health board about one patient—now dead—who was getting more care co-ordination from the north Wales police than from the mental health services, but I do not get even acknowledgement or receipt of letters.' False allegations were made against him; he was exonerated each time, and finally accepted a job offer in Canada. However, a letter received from him this week states, 'A merger of health boards across north Wales put Wrexham-based staff in charge of the entire service. Bullying, thuggery, summary dismissals based on trumped-up charges, invented sexual abuse allegations became par for the course; staff who raised safety concerns were told they were not team players and were dismissed. Some politicians at least acknowledge the receipt of letters from senior staff drawing their attention to these issues. Mr Drakeford never did. His recent comments on what happened have been jaw-droppingly wrong.'

Responding here to the 2018 statement by the then health Secretary Vaughan Gething on the Health and Social Care Advisory Service report on the Tawel Fan ward, I stated:

'in 2015, Welsh Government, the health board and Healthcare Inspectorate Wales all accepted the findings of Donna Ockenden's 2015 report.'

So, why now, when many serious allegations are peppered throughout the HASCAS report, has it come to the bizarre conclusion that care was good and that institutional abuse didn't happen? The 2018 Ockenden review found that the systems, structures and processes of governance, management and leadership introduced by the health board from 2009 were wholly inappropriate and significantly flawed. In January 2019, Donna Ockenden revealed that staff had told her services were going backwards. Two patients in north Wales mental health units have died from hanging and attempted hanging over the last year. Last month, a Public Services Ombudsman for Wales report revealed that the health board had made a fulsome apology to the son of a lady who had received treatment on the Hergest ward, David Graves, for the failings identified and injustice caused to him and his family. In a letter to the Older People's Commissioner for Wales, the health board's executive director of nursing and midwifery stated that Mr Graves had at times been verbally aggressive and made expressions that have forced the health board to consider the safety of the individual. In response, Donna Ockenden wrote, 'I have always found you, Mr Graves, polite and courteous.'

Yesterday, North Wales Community Health Council's chief officer wrote to me ahead of this debate, stating that when it comes to implementing recommendations of challenging reports, Betsi Cadwaladr University Health Board have been slow to act, some may say reluctant. Our motion therefore calls on the Welsh Government to apologise to staff, patients and the families of those adversely affected and to undertake a fundamental review of mental health services across Wales with patients, families, professionals and other stakeholders. This whole episode has been a disgrace, and a stain on the reputation of this establishment and the Government of Wales.