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An independent review of actions taken by Abertawe Bro Morgannwg University Health Board (UHB) between 2011 and 2013 in relation to the Kris Wade case is today published by Healthcare Inspectorate Wales (HIW).


Between 2011 and 2013, three female patients made allegations of sexual abuse against Kris Wade, who was employed by the health board.


He was subsequently arrested and convicted of murder in 2016\. At the time of his arrest, he was still an employee of the health board but not working with patients due to his suspension. He had been suspended from work since 2012 pending the outcome of the health board’s disciplinary investigation following the abuse allegations.


Following his conviction, the health board carried out an internal review of the events to look at how it handled the allegations made by its patients and the subsequent disciplinary process. The health board’s review found shortcomings in its processes and established an action plan for improvement.


I asked HIW to carry out this special review to be assured that appropriate actions had been identified by Abertawe Bro Morgannwg UHB and that effective arrangements had subsequently been put in place across the organisation to monitor the implementation of any changes in policies and procedures. 


HIW has identified the following weaknesses:


* Quality and safety governance arrangements
* Adult safeguarding
* Incident reporting
* Staff recruitment and employment


The issues regarding quality and safety governance arrangements are particularly disappointing as similar issues were highlighted in the *Trusted to Care* report*.* 


HIW confirms the health board has made changes to improve its governance and reporting structure, particularly in terms of escalation of concerns to board level and the sharing of learning at an operational level throughout the health board. However this progress needs to be more rapid. 


A new executive team is in place at Abertawe Bro Morgannwg UHB and I am assured they are taking forward improvements in the areas highlighted by HIW and are committed to getting it right to ensure the quality and safety of care provided to patients is at the heart of what they are implementing. 


The report makes 24 recommendations, three of which fall to Welsh Government to implement on an all\-Wales basis.


I expect the health board to take full account of the findings and recommendations from this report; ensure that they are addressed and to embed changes to policies and procedures. 


The NHS Delivery Unit will continue to work with the health board to provide support to ensure it meets the recommendations in full.  


The health board must provide assurance about its quality and safety governance arrangements, including scrutinising safeguarding concerns. This will be verified by inspection processes.


At an all Wales level, I accept the three recommendations for the Welsh Government in their entirety.


Patient safety is of paramount importance; robust safeguarding and governance processes are essential to protect adults at risk.


Completion of Disclosure and Barring Service (DBS) checks and their renewal is an important part of safeguarding patients. I will ask employers and social partners for urgent advice about the most effective way to implement this recommendation across Wales. Once an approach is agreed, these measures will be implemented as quickly as possible.


I have asked the National Independent Safeguarding Board to work with the NHS to further improve existing mechanisms for sharing safeguarding learning.


Work is well progressed by Safeguarding Boards in Wales, supported by the Welsh Government, to deliver safeguarding procedures which build upon existing statutory guidance. I will ask Safeguarding Boards to take account of the findings of this report as part of their work.


I expect all health boards to consider HIW’s findings and recommendations in full.


I am sure this will be very difficult day for the women involved in this case and for their families. My thoughts are with them and I am very grateful for their contribution to this special review.







Translation:


 
Heddiw, mae adolygiad annibynnol a gynhaliwyd o'r camau a gymerwyd gan Fwrdd Iechyd Prifysgol Abertawe Bro Morgannwg rhwng 2011 a 2013 mewn perthynas ag achos Kris Wade yn cael ei gyhoeddi gan Arolygiaeth Gofal Iechyd Cymru.


Rhwng 2011 a 2013, gwnaeth tair menyw a oedd yn gleifion ym Mwrdd Iechyd Prifysgol Abertawe Bro Morgannwg honiadau o gam\-drin rhywiol yn erbyn Kris Wade, un o gyflogeion y Bwrdd Iechyd.


Cafodd ei arestio wedi hynny a'i gael yn euog o lofruddiaeth yn 2016\. Adeg ei arestio, roedd yn cael ei gyflogi gan y Bwrdd Iechyd ond nid oedd yn gweithio gyda chleifion oherwydd iddo gael ei ddiarddel o'i waith. O ganlyniad i'r honiadau o gam\-drin, roedd wedi cael ei ddiarddel ers 2012 gan ddisgwyl canlyniad ymchwiliad disgyblu'r Bwrdd Iechyd.


Wedi iddo gael ei euogfarnu, cynhaliwyd ymchwiliad mewnol gan y Bwrdd Iechyd o'r digwyddiadau i ystyried sut yr oedd wedi ymdrin â'r cyhuddiadau a wnaed gan ei gleifion a'r broses ddisgyblu a ddaeth wedi hynny. Daeth adolygiad y Bwrdd Iechyd i'r casgliad bod diffygion yn ei brosesau a phennwyd cynllun gweithredu ar gyfer gwella.


Gofynnais i Arolygiaeth Gofal Iechyd Cymru gynnal adolygiad arbennig er mwyn cael sicrwydd bod y camau priodol wedi cael eu nodi gan Fwrdd Iechyd Prifysgol Abertawe Bro Morgannwg a bod trefniadau effeithiol wedi cael eu rhoi ar waith ar ôl hynny ar draws y sefydliad i fonitro'r modd y mae unrhyw newidiadau i bolisïau a gweithdrefnau yn cael eu rhoi ar waith.  


Mae Arolygiaeth Gofal Iechyd Cymru wedi nodi'r gwendidau canlynol:


* Trefniadau llywodraethu ansawdd a diogelwch
* Diogelu oedolion
* Adrodd ar ddigwyddiadau
* Trefniadau recriwtio a chyflogaeth staff


Mae'r materion sy'n gysylltiedig â threfniadau llywodraethu ansawdd a diogelwch yn arbennig o siomedig gan fod yr adroddiad *Ymddiried mewn Gofal* wedi tynnu sylw at faterion tebyg. 


Mae'r Arolygiaeth yn cadarnhau bod y Bwrdd Iechyd wedi gwneud newidiadau i wella ei strwythur llywodraethu ac adrodd, yn arbennig o ran uwchgyfeirio pryderon i lefel bwrdd a rhannu dysgu ar lefel weithredol drwy'r Bwrdd Iechyd cyfan. Fodd bynnag, mae angen i'r cynnydd ar y mater hwn gan y Bwrdd Iechyd ddigwydd yn gyflymach.  


Mae gan Fwrdd Iechyd Prifysgol Abertawe Bro Morgannwg dîm gweithredol newydd ac rwyf wedi cael sicrwydd eu bod yn gwneud gwelliannau yn y meysydd a amlygwyd gan yr Arolygiaeth a'u bod wedi ymrwymo i sicrhau bod ansawdd a diogelwch gofal a ddarperir i gleifion wrth galon pob dim sy'n cael ei wneud.  


Gwneir 24 o argymhellion yn yr adroddiad, a chyfrifoldeb Llywodraeth Cymru yw gweithredu tri ohonynt ar sail Cymru gyfan.  


Disgwyliaf i'r Bwrdd Iechyd ystyried canfyddiadau ac argymhellion yr adroddiad hwn yn llawn, a sicrhau eu bod yn cael sylw, ac ymwreiddio unrhyw newidiadau i bolisïau a gweithdrefnau.  


Bydd Uned Gyflawni'r Gwasanaeth Iechyd Gwladol yn parhau i weithio gyda'r Bwrdd Iechyd i roi cymorth a sicrhau ei fod yn bodloni'r argymhellion yn llawn.   


Rhaid i'r Bwrdd Iechyd roi sicrwydd ynglŷn â'i drefniadau llywodraethu ansawdd a diogelwch, gan gynnwys rhai pryderon ynghylch diogelu. Bydd hyn yn cael ei wirio gan broses arolygu.


Ar lefel Cymru gyfan, rwy'n derbyn y tri argymhelliad ar gyfer Llywodraeth Cymru yn llawn. 


Mae diogelwch cleifion yn hollbwysig ac mae'n hanfodol bod prosesau diogelu a llywodraethu cadarn yn eu lle i ddiogelu oedolion sydd mewn perygl.


Er mwyn diogelu cleifion, mae’n hollbwysig bod gwiriadau'r Gwasanaeth Datgelu a Gwahardd yn cael eu cwblhau a'u hadnewyddu. Byddaf yn gofyn i gyflogwyr a phartneriaid cymdeithasol am gyngor ar fyrder am y dull mwyaf effeithiol o weithredu'r argymhelliad hwn ledled Cymru. Pan geir cytundeb ynglŷn â’r dull, bydd y mesurau hyn yn cael eu rhoi ar waith mor gyflym â phosibl. 


Rwyf wedi gofyn eisoes i'r Bwrdd Diogelu Annibynnol Cenedlaethol weithio'r gyda'r Gwasanaeth Iechyd i wella ymhellach y mecanweithiau presennol ar gyfer rhannu'r hyn a ddysgwyd o ran diogelu.


Mae cynnydd da yn cael ei wneud gan Fyrddau Diogelu yng Nghymru o safbwynt y gwaith hwnnw, gyda chymorth Llywodraeth Cymru, i ddarparu gweithdrefnau diogelu sy'n adeiladu ar y canllawiau statudol presennol. Byddaf yn gofyn i Fyrddau Diogelu ystyried canfyddiadau'r adroddiad hwn fel rhan o'u gwaith. 


Disgwyliaf i bob bwrdd iechyd ystyried canfyddiadau ac argymhellion yr Arolygiaeth Gofal Iechyd Cymru yn llawn.


Rwy'n siŵr y bydd hwn yn ddiwrnod anodd i'r menywod dan sylw, ac i'w teuluoedd. Rwy'n meddwl amdanynt ac rwy'n ddiolchgar iawn iddynt am eu cyfraniad i'r adolygiad arbennig hwn.