Openness, transparency, and the ability to raise safeguarding concerns in the NHS have once again been highlighted in a critical report by Wales’s health watchdog.
In an independent review, HIW (Healthcare Inspectorate Wales) found that investigations into sexual-assault allegations against care worker Kris Wade were bungled – with senior health board staff not appreciating their seriousness or complexity.
Wade later admitted the brutal murder of a neighbour in Cardiff Bay in 2016, while suspended from his job with ABMU (Abertawe Bro Morgannwg University Health Board).
The HIW review was carried out following pressure from BMA Cymru Wales after an initial review was carried out by the health board itself.
BMA Welsh council chair David Bailey (pictured below) said: ‘When we called for the independent report in 2017 we said that health boards should not investigate serious concerns about themselves.
‘HIW’s report confirms this and shows that there is still work to be done to improve the governance processes of health boards throughout Wales.’
Wade, whose father was the former clinical director of the health board’s learning disabilities directorate, had originally worked in the IT department. He was moved to the learning disabilities directorate as a nursing assistant in 2004 after concerns that screen time was affecting his health.
No vacancy form was filled in and no police checks were ever carried out on him. HIW found that 142 of the 2,000 staff working in ABMU’s mental health and learning disabilities service delivery unit did not have DBS checks or renewed checks.
In 2011, at an assessment and treatment unit in Cardiff, Wade was accused of sexual assault by a female patient. He was placed on special leave but after a police investigation and a disciplinary review, no further action was taken. He returned to work at a second residential unit.
HIW said there was an unacceptable delay in recognising and reporting the first allegation as a safeguarding issue.
In October 2012, a second patient made another sexual assault allegation against Wade in a text message to a nurse. He was again placed on special leave while the police investigated. The CPS decided not to prosecute.
In February the following year, an internal health board investigation concluded that a full investigation would not uncover any more evidence. However, a third allegation was made of abuse dating back to 2011 and Wade was formally suspended while the police investigated all three allegations.
It was while he was suspended that Wade carried out the sexually motivated murder of 65-year-old neighbour Christine James. He was eventually dismissed from his job for gross misconduct while in custody. All three allegations were proven by a disciplinary panel.
ABMU’s ‘desktop review’ into its processes following this said Wade’s actions outside of his employment could not have been predicted or prevented. However, HIW said this assertion was not evidence-based.
HIW’s report also said that while improvements had been made, the health board still had work to do. It also highlighted the fact that while individual board members knew of the allegations against Wade, the case was never formally reported to the board.
The BMA’s Dr Bailey said: ‘Despite concerns being raised by us for a number of years, it is disappointing that the report found that the reporting structure for quality and safety remains unclear.
‘The health board has had a significant amount of time to rectify this and has not done so. It is imperative that they now take urgent steps to put in a robust structure to ensure the safeguarding of patients.
‘It is deeply troubling that the report found that “some executive Board” members were individually aware of the details of the allegations against Mr Wade throughout the investigation and that these were not formally reported to the board.
He added: ‘This report highlights the dire need for an individual within health boards with whom staff can raise concerns. BMA Cymru Wales stands ready to work with the Welsh Government and health boards to implement these recommendations.’
Protection of adults
In total, HIW has made 24 recommendations for improvements focusing on quality- and safety-governance arrangements, adult safeguarding, incident reporting, and staff recruitment and employment.
Chief executive Kate Chamberlain said: ‘There are areas of learning within this review which are relevant to the NHS as a whole and we expect all health boards to consider our findings and recommendations.
‘This case highlights the importance of safeguarding and governance processes which are essential in protecting adults at risk.
‘The robustness of these processes is intrinsic to the confidence that patients and their families have in the safeguarding system as a whole.’
The Welsh Government has accepted the report and has said that three recommendations will be implemented across Wales.
ABMU chief executive Tracy Myhill said much had changed in the 15 years since Wade was first employed.
She said: ‘There are now much stricter recruitment and employment processes in place at a local and national level. However, we agree with HIW that even more can be done.
‘The HIW report calls for improvements to DBS checks at an all-Wales level. While a check would not have made a difference to Mr Wade’s employment, we agree that more robust DBS procedures can only improve patient safeguarding generally.’