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Ar 14 Gorffennaf, cyhoeddais yn llawn a heb ei olygu, adroddiad annibynnol Dr Margaret Flynn i achosion o esgeulustod a cham\-drin yn ne\-ddwyrain Cymru a ddaeth yn adnabyddus fel Ymgyrch Jasmine, sef enw ymchwiliad cysylltiedig gan yr heddlu. Roedd adroddiad Dr Flynn yn manylu mewn cronoleg a dadansoddiad cynhwysfawr y drasiedi a ddigwyddodd i dros gant o ddioddefwyr a'u teuluoedd.  

Bydd Aelodau'n cofio yn y cyfarfod llawn ar y diwrnod hwnnw, sut y daeth pob ochr o’r Cynulliad ynghyd i gydymdeimlo â'r teuluoedd dan sylw, ac i ymrwymo i weithio gyda'i gilydd i wneud yn siŵr na fyddai’r digwyddiadau erchyll hyn yn digwydd eto yn y dyfodol. 

Roedd adroddiad Dr Flynn yn cynnwys 12 o argymhellion pwysig. Wrth wneud Datganiad Llafar ar y diwrnod pan gyhoeddwyd yr adroddiad, ymrwymais i ddychwelyd at aelodau yn y sesiwn hon i roi’r newyddion diweddaraf iddynt am ymateb Llywodraeth Cymru. Fodd bynnag, gan fod mwyafrif yr argymhellion yn ymwneud â sefydliadau y tu allan i gylch gwaith Llywodraeth Cymru, dywedais wrth aelodau ar y diwrnod hwnnw hefyd fy mod wedi ysgrifennu at yr amrywiol bartïon, i ofyn am eu hymateb. 

Felly, gallaf heddiw amlinellu ymateb Llywodraeth Cymru i'r pedwar argymhelliad a gyfeiriwyd ati neu at y GIG yng Nghymru, ynghyd â'r rheini gan gyrff perthnasol eraill. Rwyf wedi cyhoeddi'r ymatebion hyn.

  
Argymhelliad 1

1\. y sector cartrefi gofal preswyl a nyrsio:

(i) yn cael ei wneud yn sector o bwys strategol cenedlaethol i Gymru, gan gydnabod bod buddsoddiad isel yn y system gofal iechyd yn golygu costau uwch i'r Gwasanaeth Iechyd Gwladol a bod hynny'n effeithio ar botensial economaidd drwy fethu hyrwyddo gweithlu modern a hyfforddedig

(ii) mabwysiadu polisïau clir i reoleiddio a galluogi ymyriad yn y 'farchnad' gofal cymdeithasol i wella ansawdd y gofal drwy fynd i'r afael yn uniongyrchol â materion fel cyflog ac amodau gwaith, lefelau staffio a gwybodaeth ac arbenigedd comisiynwyr gwasanaethau a ariennir yn gyhoeddus

(iii) sicrhau bod rheolwyr cartrefi gofal wedi eu cofrestru, ac yn aelodau o gorff proffesiynol sy'n pennu safonau proffesiynol, yn meddu ar bwerau disgyblu ac yn rhoi llais iddynt ar bolisi cenedlaethol, a

(iv) datblygu dangosyddion ansawdd credadwy i lywio cynllunio strategol ar gyfer iechyd a gofal cymdeithasol 

Mae Llywodraeth Cymru yn derbyn yr argymhelliad hwn.

Mae Llywodraeth Cymru yn cytuno â Dr Flynn bod y sector gofal cymdeithasol yn sector o bwys cenedlaethol mawr. Mae hyn yn wir nid yn unig oherwydd ei bwysigrwydd ym mywydau nifer o bobl, ond oherwydd ei berthynas agos â gwasanaethau cyhoeddus eraill \- iechyd yn amlwg, ond hefyd tai, hamdden ac amrywiaeth o wasanaethau cyhoeddus. 

Mae ein Bil Rheoleiddio ac Arolyguac Gofal Cymdeithasol (Cymru)  yn amlinellu pwerau newydd i Weinidogion Cymru lywio'r farchnad yn y ffordd a ddisgrifir gan Dr Flynn. Mae'r Gweinidog Iechyd a Gwasanaethau Cymdeithasol hefyd yn ymchwilio ar hyn o bryd i sut y mae pethau fel cyflog ac amodau yn effeithio ar ansawdd gwasanaethau yn y sector. 

Credaf fod sefydlu Gofal Cymdeithasol Cymru drwy'r Bil Rheoleiddio ac Arolygu Gofal Cymdeithasol (Cymru) yn ddull pwerus i gyflawni argymhellion Dr Flynn mewn perthynas â rheolwyr. Bydd yn cadw cofrestr o reolwyr, rhoi llwybr clir iddynt ar gyfer datblygu gyrfa a chynnig fforwm iddynt drafod a chyfrannu at ddatblygu syniadau ar bob lefel.  

O ran dangosyddion ansawdd, mae'r Llywodraeth wedi nodi o'r dechrau gwasanaeth hwn ei hymrwymiad i roi dulliau effeithiol ar waith i fesur yr effaith y mae gwasanaethau yn ei chael ar fywydau pobl. Mae'r fframwaith canlyniadau cenedlaethol ar gyfer pobl sydd angen gofal a chymorth o dan y Ddeddf Gwasanaethau Cymdeithasol a Llesiant yn nodi beth mae llesiant yn ei olygu i bobl sydd angen gofal a chymorth a sut y byddwn yn mesur a yw llesiant yn cael ei gyflawni. Bydd nifer o wasanaethau yn cefnogi pobl i gyflawni llesiant, ac mae hyn yn cynnwys y sector cartrefi gofal preswyl a nyrsio. Bydd y fframwaith canlyniadau yn darparu gwell tryloywder ar p'un a yw gwasanaethau gofal a chymorth yn gwella canlyniadau llesiant ar gyfer pobl sydd angen gofal a chymorth a gofalwyr sydd angen cymorth yng Nghymru gan ddefnyddio dangosyddion cyson y mae modd eu cymharu. Bydd hyn yn dangos beth sydd angen ei wneud i wella llesiant pobl yn hytrach na chanolbwyntio ar y prosesau sy'n ymwneud â darparu gwasanaethau cymdeithasol. 

  
Argymhelliad 2

2\. Llywodraeth Cymru, mewn cydweithrediad ag Iechyd Cyhoeddus Cymru, yn sicrhau bod:  
(i) arwyddocâd briwiau pwysedd dwfn yn cael ei ddyrchafu i gyflwr hysbysadwy  
(ii) uwch\-glinigwyr, gan gynnwys Cofrestryddion, Meddygon Teulu a Nyrsys Hyfywedd Meinwe, yn cymryd rôl arweiniol i atal briwiau pwysedd y gellir eu hosgoi ac i ddatblygu Cofrestrfa Glwyfau Genedlaethol, gyda chymorth y Ganolfan Arloesi ym maes Gwella Clwyfau  
(iii) uwch\-glinigwyr yn gyfrifol am hysbysu Iechyd Cyhoeddus Cymru am friwiau pwysedd dwfn a  
(iv) lle mae Iechyd Cyhoeddus Cymru wedi cael ei hysbysu am fodolaeth briwiau pwysedd dwfn, bod proses lle mae'r wybodaeth honno yn cael ei chyfleu i Arolygiaeth Gofal a Gwasanaethau Cymdeithasol Cymru neu Arolygiaeth Gofal Iechyd Cymru ac awdurdodau comisiynu priodol yn ogystal â theuluoedd pobl

  
Mae Llywodraeth Cymru yn derbyn yr argymhelliad hwn. 

Bydd Llywodraeth Cymru yn cyflwyno system monitro ac adrodd newydd i gofnodi a chyhoeddi achosion o niwed pwysedd y gellir ei osgoi mewn cartrefi gofal a chynyddu'r cymorth sydd ar gael i fynd i'r afael â methiannau yn y system. 

Bydd rhaglen raddol o waith yn cael ei chynnal i gyflwyno system adrodd newydd fel bod modd adrodd ar achosion fesul mis; yna, caiff yr wybodaeth hon ei chyhoeddi ar wefan gyhoeddus.. Bydd Iechyd Cyhoeddus Cymru yn rhan o'r gwaith datblygu hwn i sicrhau bod ei swyddogaeth arsyllu a'i swyddogaeth i wella gwasanaethau yn cael eu defnyddio dan y trefniadau newydd.

Wrth wneud y gwaith hwn, derbynnir y bydd diffiniadau Panel Cynghori Ewrop ar wlserau yn cael eu defnyddio. Felly, bydd y system adrodd newydd a'r gofrestrfa clwyfau y cyfeirir atynt yn yr argymhellion yn canolbwyntio ar wlserau gradd 3, 4 a rhai nad oes modd eu gosod mewn unrhyw ddosbarth.

Mae Llywodraeth Cymru yn derbyn bod cyflwyno'r trefniant newydd hwn yn rhoi ysgogiad i welliannau a welwyd eisoes o ganlyniad i argymhellion Ymddiried mewn Gofal (2014\) yn y GIG yng Nghymru.

  
Argymhelliad 3

3\. proses Amddiffyn Oedolion Agored i Niwed:  
(i) diffinio ei swyddogaethau'n fwy cul ac yn fwy realistig  
(ii) cryfhau canlyniadau amddiffynnol i unigolion lle ceir honiad neu dystiolaeth bod niwed wedi digwydd, drwy sicrhau bod naill ai asesiad gofal neu adolygiad o gynllun gofal yr unigolyn hwnnw yn cael ei gynnal. Dylai'r broses arwain at weithredu penodol yn hytrach na phenderfyniad yn unig, er enghraifft penderfyniad o gam\-drin sefydliadol  
(iii) sicrhau bod y GIG yn atebol am gyflawni ei gyfrifoldeb arweiniol ar gyfer ymchwilio i gyflyrau mawr a allai fod yn farwol fel briwiau pwysedd dwfn yn y sector gofal preswyl a nyrsio

  
Mae Llywodraeth Cymru yn derbyn yr argymhelliad hwn.

Drwy ein Deddf Gwasanaethau Cymdeithasol a Llesiant (Cymru) 2014, rydym yn darparu fframwaith cryfach i amddiffyn oedolion sy’n agored i niwed, a luniwyd drwy raglen gynhwysfawr o ymgysylltu a chyd\-gynhyrchu gyda’r sector a dinasyddion. 

Bydd y gwaith hwn yn cryfhau ac yn gwella arferion diogelu, gan roi cyfarwyddiadau i fyrddau iechyd a phartneriaid perthnasol eraill wrth arfer eu dyletswydd i adrodd am oedolion yr amheuir eu bod yn cael eu cam\-drin neu eu hesgeuluso, neu sydd mewn perygl o fod. Rhaid i ganlyniad ymholiad diogelwch gael ei gofnodi yng nghynllun gofal a chymorth unigolyn, gan gynnwys pa gamau diogelwch a chamau gweithredu cysylltiedig a gaiff eu cymryd a chan bwy, er mwyn sicrhau canlyniadau gwell ar gyfer yr unigolyn hwnnw.           

Bydd canllawiau a gweithdrefnau diwygiedig yn deillio o weithredu’r Ddeddf ym mis Ebrill 2016, ac yn sicrhau mwy o atebolrwydd ac arferion cyson gan weithwyr proffesiynol ar bob lefel ar draws y maes iechyd, awdurdodau lleol a’r heddlu i amddiffyn oedolion a phlant sy’n agored i niwed. Bydd hyn yn sicrhau ymatebion priodol ac amserol i bryderon sy’n adlewyrchu cyfrifoldebau penodol partneriaid diogelu, yn unigol a gyda’i gilydd, i arwain a mynd i’r afael   phryderon neu gyflyrau, gan gynnwys briwiau pwysedd dwfn. Bydd y gwersi sy'n deillio o achosion fel hyn yn cael eu defnyddio i wneud gwelliannau ar draws sefydliadau fel rhan o amgylchedd o heriau cadarn a chefnogol.

Argymhelliad 4

4\. Dylid cynnal cwest, er gwaethaf y ffaith bod marwolaethau Stanley Bradford, Megan Downs, Edith Evans, Ronald Jones ac eraill yn hysbys i’r Crwner ac wedi’u cofrestru eisoes  
 

Derbyniais ymateb gan Grwner Gwent, David T Bowen ar 21 Awst. Mae eisoes wedi cynnal cyfarfodydd gyda chynrychiolwyr o Ymgyrch Jasmine a'r Awdurdod Gweithredol Iechyd a Diogelwch i drafod ffordd ymlaen. 

Ysgrifennodd Mr Bowen i mi eto ar 30 Medi gyda diweddariad, gan ddweud ei fod mewn cysylltiad â rhanddeiliaid perthnasol ac mae bellach yn gwbl glir bod nifer o'r marwolaethau y cyfeirir atynt yn adroddiad Dr Flynn digwydd y tu allan i'w awdurdodaeth. Mr Bowen yn dod i'r casgliad ei ddiweddariad drwy rhoi tawelwch meddwl i mi lle y mae ganddo awdurdodaeth, a lle mae'r gyfraith yn mynnu, bydd cwest yn cael ei gynnal ac mae eisoes yn gweithio i'r perwyl hwnnw.

Argymhelliad 5

5\. Bod Heddlu Gwent yn rhoi’r wybodaeth a baratowyd gan aelodau'r panel arbenigol i deuluoedd y bobl hŷn yn y chwe chartref sy’n rhan o Ymgyrch Jasmine ac yn sicrhau bod y teuluoedd hyn yn cael cymorth yn ystod y broses hon ac ar ôl hynny  
 

Ysgrifennodd Prif Gwnstabl Heddlu Gwent, Jeff Farrar ataf yn gyntaf ar 15 Gorffennaf yn cydnabod adroddiad Dr Flynn ac yn cefnogi'r argymhelliad y dylai Heddlu Gwent roi’r wybodaeth gan y panel o arbenigwyr, i deuluoedd. Fodd bynnag, er mai Heddlu Gwent fyddai’n dal yr wybodaeth hon, byddai angen i Mr Farrar drafod y mater gyda'r Awdurdod Gweithredol Iechyd a Diogelwch a Gwasanaeth Erlyn y Goron i sicrhau ei fod yn gyfreithiol briodol i wneud hynny gan mai'r Awdurdod Gweithredol Iechyd a Diogelwch sydd bellach yn gyfrifol am erlyniad Dr Das, erlyniad sydd wedi’i atal ar hyn o bryd.   
Ar 25 Medi, derbyniais ail lythyr yn dweud bod cyfarfod wedi’i gynnal rhwng Heddlu Gwent, yr Awdurdod Gweithredol Iechyd a Diogelwch a Gwasanaeth Erlyn y Goron. Mae Mr Farrar yn mynd ymlaen i ddweud, yng ngoleuni ymchwiliadau’r crwner sydd ar y gweill, ac y mae disgwyl iddynt gael eu cynnal gan Mr David Bowen, Crwner Ei Mawrhydi yng Ngwent, y gallai tystion arbenigol gael eu galw i roi tystiolaeth yn y gwrandawiadau hyn, ac y byddai datgelu’r wybodaeth hon ar hyn o bryd yn niweidiol i ymchwiliadau’r crwner.

Argymhelliad 6

6\. Bod GIG Cymru yn ystyried sut y mae uwch\-glinigwyr yn ymgymryd â’r cyfrifoldeb am roi gwybod i'r Crwner am farwolaethau mewn ysbytai ac yn ystyried yr angen am ragdybiaeth gyfreithiol o blaid rhoi gwybod i'r Crwner am farwolaethau preswylwyr cartrefi preswyl a nyrsio

  
Mae'r argymhelliad hwn wedi'i anelu at GIG Cymru. Fodd bynnag, gan ei fod yn ymwneud â hysbysu'r crwner am farwolaethau, cyfrifoldeb y Weinyddiaeth Gyfiawnder yw hynny. Felly, rwyf wedi ysgrifennu'n bersonol at yr Ysgrifennydd Gwladol i dynnu ei sylw at adroddiad Adolygiad Flynn a gofyn iddo ymateb i'r argymhelliad hwn, y byddaf yn ei gyhoeddi cyn hir ynghyd  ’r rhai eraill, ar ein gwefan.    
Mae'n bwysig nodi fodd bynnag bod Byrddau Iechyd Lleol Cymru, ers 2012, wedi datblygu a chyflwyno proses o adolygu nodiadau achos marwolaethau cleifion sy’n marw mewn ysbytai acíwt. Mae dwy ran i’r broses hon: mae’n rhoi cyfle i nodi them u a meysydd i’w gwella; mae hefyd yn rhoi sicrwydd i deuluoedd bod y gofal wedi cael ei adolygu, ac os bydd unrhyw bryderon yn codi, yna bydd yn destun adolygiad manylach. Ar hyn o bryd, mae adolygiadau o farwolaethau wedi’u cyfyngu i ysbytai yn y rhan fwyaf o ardaloedd, ond y bwriad yw eu hehangu i gynnwys marwolaethau sy'n digwydd yn y gymuned o dan ofal meddygon teulu. Mae’r broses hon yn cael ei chynllunio i sicrhau y bydd yn gallu addasu i newidiadau a fydd yn digwydd i’r broses o lunio tystysgrifau marwolaeth yn y dyfodol, sy’n cael eu cyflwyno gan Lywodraeth y DU, gan gynnwys cyflwyno swyddi Archwilwyr Meddygol. 

Fel y nodwyd yn flaenorol, nid yw mwyafrif yr argymhellion yn yr adroddiad yn ymwneud â Llywodraeth Cymru na chyrff y mae'n gyfrifol amdanynt. Fodd bynnag, rwyf wedi ysgrifennu at bob un o'r cyrff hynny yn gofyn am ymateb. 

Er budd yr aelodau fodd bynnag, rwyf wedi rhestru'r argymhellion eraill isod, ynghyd â rhywfaint o wybodaeth am yr ymatebion gan y cyrff perthnasol:

  
Argymhelliad 7

7\. Bod y Cyngor Meddygol Cyffredinol (GMC) yn:  
(i) cydweithio â GIG Cymru i ganfod ffyrdd o reoli gwrthdaro buddiannau sy'n codi yn sgil derbyn cleifion Meddygon Teulu ac unigolion cofrestredig eraill y Cyngor Meddygol Cyffredin (meddygon ymgynghorol mewn ysbytai er enghraifft) i gartrefi preswyl a nyrsio lle mae meddygon o'r fath yn gyfarwyddwyr cwmni, neu'n perthyn i gyfarwyddwyr y cartrefi hyn  
(ii) sicrhau bod pob Meddyg Teulu ac unigolion cofrestredig eraill y Cyngor Meddygol Cyffredinol yn cael gwybod am yr hyn sy'n cyfrif fel gwrthdaro buddiannau a sut i reoli hyn yn ymarferol. O ystyried y byddai datgan gwrthdaro ar ei ben ei hun wedi bod yn ddull diogelu annigonol o ystyried canfyddiadau'r Adolygiad hwn, efallai y bydd y Cyngor Meddygol Cyffredinol am ystyried yr enghraifft benodol o glinigwyr sy’n berchen ar gartrefi nyrsio a gofal  
(iii) ystyried yn ei adolygiad o'r Gofrestr Feddygol, y potensial ar gyfer cofnodi gwybodaeth am wrthdaro buddiannau sydd wedi'i ddatgan  
 

Derbyniais ymateb gan Niall Dickson, Prif Weithredwr y Cyngor Meddygol Cyffredinol, ar 24 Awst.

Yn ei lythyr, dywedodd Mr Dickson bod y Cyngor Meddygol Cyffredinol yn derbyn argymhelliad 7(i) yn llawn, ac y bydd yn cydweithio â GIG Cymru i weld pa gamau pellach y gellir eu cymryd. Mae'n dweud bod adroddiad Dr Flynn yn dangos pa mor bwysig yw bod meddygon yn agored ac yn onest wrth ddatgan unrhyw wrthdaro buddiannau posibl ac na ddylent byth â gadael i unrhyw wrthdaro o'r fath ddylanwadu ar y gofal neu'r driniaeth y mae cleifion yn eu derbyn. 

Caiff Argymhelliad 7(ii) hefyd ei dderbyn, mewn egwyddor. Bydd y Cyngor Meddygol Cyffredinol yn parhau i godi ymwybyddiaeth ymhlith meddygon am ein canllawiau presennol ar drefniadau ariannol a masnachol a gwrthdaro buddiannau, sy'n nodi'n glir y dylai meddygon ddatgan unrhyw fuddiannau mewn cartrefi nyrsio neu gartrefi gofal, gan gynnwys buddiannau pobl sy'n agos atynt. Mae Mr Dickson yn dweud wrthyf y bydd y Cyngor Meddygol Cyffredinol yn datblygu adnoddau ychwanegol, fel astudiaethau achos, i helpu meddygon i ddeall eu cyfrifoldebau yn ymarferol. 

O ran perchnogaeth cartrefi nyrsio a chartrefi gofal, bydd y Cyngor Meddygol Cyffredinol yn gweithio gydag Arolygiaeth Gofal Iechyd Cymru i edrych ar ba gamau effeithiol pellach y gellir eu cyfiawnhau, a bydd hefyd yn gweithio gydag Arolygiaeth Gofal Iechyd Cymru i weld a ydynt yn dymuno rhoi unrhyw gyfyngiadau yn eu lle.

Mewn ymateb i argymhelliad 7(iii) mae Mr Dickson yn fy hysbysu eu bod eisoes yn ystyried cynnwys gwrthdaro buddiannau ar y gofrestr feddygol, fel rhan o'u hadolygiad presennol o'r Rhestr o Ymarferwyr Meddygol Cofrestredig.

Byddwn yn ysgrifennu at gyrff proffesiynol a phwyllgorau meddygol lleol meddygon teulu, i dynnu eu sylw at y negeseuon allweddol sy’n codi o’r adroddiad a'u hatgoffa i reoli gwrthdaro buddiannau (gan gynnwys cysylltiadau teuluol). Gofynnir i bob corff a phwyllgor ystyried yr argymhellion a chryfhau canllawiau sy’n ymwneud   gwrthdaro buddiannau fel sy’n briodol.   
Byddwn hefyd yn ysgrifennu at y Cyngor Meddygol Cyffredinol a GIG Cymru yn gofyn iddynt gwrdd â Llywodraeth Cymru i nodi ffyrdd o waredu/ lleihau / rheoli'r achosion penodol hyn o wrthdaro buddiannau mewn perthynas â chartrefi preswyl a nyrsio pan fo meddygon yn gyfarwyddwyr cwmni, neu'n perthyn i gyfarwyddwyr y cartrefi hyn. Yn ogystal â hyn, byddwn yn gweithio'n agos ag Arolygiaeth Gofal a Gwasanaethau Cymdeithasol Cymru (AGGCC), Arolygiaeth Gofal Iechyd Cymru a'r Byrddau Iechyd i weld a oes angen ystyried unrhyw newidiadau i ddeddfwriaeth reoleiddiol a / neu safonau cenedlaethol.  
       
Argymhelliad 8

8\. Bod y Cyngor Meddygol Cyffredinol a'r Cyngor Nyrsio a Bydwreigiaeth yn ystyried yr angen am ddiwygio parhaus i sicrhau bod gweithdrefnau addasrwydd i ymarfer yn cael eu cynnal mor gyflym ag sy'n ymarferol, wrth gynnal eu prif ddiben o amddiffyn y cyhoedd  
 

Mewn perthynas ag argymhelliad 8, sydd wedi'i anelu'n benodol at y Cyngor Meddygol Cyffredinol a'r Cyngor Nyrsio a Bydwreigiaeth, gallaf gadarnhau bod y Cyngor Meddygol Cyffredinol yn derbyn hyn yn llawn ac eisoes wedi ymrwymo i ddiwygio eu gweithdrefnau addasrwydd i ymarfer drwy newid y ffordd y maent yn ymchwilio i achosion a symleiddio eu prosesau dyfarnu. 

Ar 4 Medi, roeddwn yn hapus cael derbyn ymateb gan Jackie Smith, Prif Weithredwr y Cyngor Nyrsio a Bydwreigiaeth, sy'n croesawu'r argymhelliad sy'n atgyfnerthu eu hamcan i gymryd camau cyflym a theg i ymdrin ag unigolion pan fo'u huniondeb neu eu gallu i ddarparu gofal diogel yn cael ei gwestiynau, gan sicrhau bod gan y cyhoedd hyder yn ansawdd a safonau'r gofal a ddarperir gan nyrsys a bydwragedd.   
Bydd hefyd o ddiddordeb i aelodau bod y Cyngor Nyrsio a Bydwreigiaeth bellach wedi gorffen ei weithdrefnau disgyblaeth mewn perthynas â'r digwyddiadau hyn, ac wedi cytuno i gwrdd â’r teuluoedd yn y dyfodol agos. 

Argymhelliad 9

9\. Bod y Cyfarwyddwr Erlyniadau Cyhoeddus yn cyfeirio Ymchwiliad Ymgyrch Jasmine at yr Adran Troseddau Arbennig a Gwrthderfysgaeth (yr Adran Troseddau Arbennig gynt) Gwasanaeth Erlyn y Goron  
 

Ar 31 Gorffennaf, derbyniais lythyr gan Alison Saunders, Cyfarwyddwr Erlyniadau Cyhoeddus mewn ymateb i argymhellion Dr Flynn. Er bod Ms Saunders yn croesawu adroddiad Dr Flynn, sy'n tynnu sylw at nifer o faterion y dylai bob asiantaeth eu hystyried a mynd i'r afael â hwy wrth symud ymlaen, mae Ms Saunders hefyd yn dweud bod yr achos hwn wedi cael ei gyfeirio at yr Adran Troseddau Arbennig yn flaenorol, a edrychodd ar y nodiadau adolygu achosion, a phenderfyniadau yn ymwneud â chyhuddiadau ac ansawdd a sicrhawyd gan gyfreithiwr profiadol o'r Adran Troseddau Arbennig. Mae Ms Saunders yn dweud nad oes angen cyfeirio’r mater eto.   
    
Argymhelliad 10

10\. Bod Cyngor Cenedlaethol Penaethiaid yr Heddlu (NPCC) yn sicrhau bod blaenoriaeth ymchwiliad heddlu yn cyflawni gallu (a) Arolygiaeth Gofal a Gwasanaethau Cymdeithasol Cymru (AGGCC) a (b) rheoleiddwyr proffesiynol, fel y Cyngor Meddygol Cyffredinol, y Cyngor Nyrsio a Bydwreigiaeth a Chyngor Gofal Cymru i ddatblygu camau gweithredu sifil a throseddol; a mynd i'r afael â phryder am addasrwydd honedig i ymarfer o fewn amserlen a ddiffinnir  
 

Argymhelliad 11

11\. Bod Cyngor Cenedlaethol Penaethiaid yr Heddlu, yr Awdurdod Gweithredol Iechyd a Diogelwch, Arolygiaeth Gofal a Gwasanaethau Cymdeithasol Cymru a'r rheoleiddwyr proffesiynol yn rhannu'r hyn a ddysgwyd o ganlyniad i’r Adolygiad hwn, gan gydweithio ymhellach i bennu a chadarnhau cydrannau fframwaith ar gyfer cynnal gweithredu amserol ar y cyd yn y dyfodol 

Ar 9 Medi, derbyniais ymateb gan y Prif Gwnstabl Sara Thornton, Cadeirydd Cyngor Cenedlaethol Penaethiaid yr Heddlu. Mae'n credu mai'r hyn sy'n ganolog i'r argymhellion yw'r angen i'r rheini sy'n ymchwilio i achosion difrifol o gam\-weithredu difrifol yn y sector gofal gydweithio'n glir ac yn effeithiol. Dylai'r holl sefydliadau a enwir ddeall a chytuno ar unrhyw ymatebion i'r argymhellion hyn.

Am y rheswm hwn, cefais un ymateb cyfunol gan y Prif Gwnstabl Sara Thornton yn nodi'r cynnydd sy'n cael ei wneud. Roedd y cydweithrediad yn cynnwys Neil Craig, Pennaeth Gwaith Maes Cymru, yr Awdurdod Gweithredol Iechyd a Diogelwch, Steve Thomas, Prif Weithredwr, Cymdeithas Llywodraeth Leol Cymru, David Francis, Dirprwy Brif Arolygwr, Arolygiaeth Gofal a Gwasanaethau Cymdeithasol Cymru, Jackie Smith, Prif Weithredwr, y Cyngor Nyrsio a Bydwreigiaeth, Niall Dickson, Prif Weithredwr, y Cyngor Meddygol Cyffredinol a Rhian Williams, Prif Weithredwr, Cyngor Gofal Cymru. 

I grynhoi, credai'r Grŵp ei bod yn werth ymateb i'r cwestiwn 'Beth fyddai'n wahanol pe bai'r digwyddiadau a arweiniodd at adroddiad Flynn yn digwydd heddiw?' yn hytrach nag ateb yr argymhellion yn uniongyrchol. 

Dywedodd y Prif Gwnstabl Thornton bod newidiadau sylweddol wedi'u gwneud i'r fframwaith deddfwriaethol yn y deng mlynedd ers dechrau Ymgyrch Jasmine, a bod cynnydd sylweddol wedi'i wneud wrth ddatblygu ein fframweithiau cydweithredol. Mae'r newidiadau hynny wedi arwain at well dealltwriaeth o rolau a chylchoedd gwaith ei gilydd; ac mae ein cydberthnasau, sy'n arwain at gydweithio, llawer yn gryfach. Cytunodd y grŵp i ddeall yn well sut i gefnogi gwaith ei gilydd i sicrhau'r ymatebion a'r canlyniadau cywir mewn modd rhagweithiol ac amserol wrth ymateb i ddigwyddiad.  

Argymhelliad 12

12\. Bod Comisiwn y Gyfraith yn adolygu'r sefyllfa gyfreithiol bresennol mewn perthynas â chwmnïau preifat gyda pherthnasedd penodol at lywodraethu corfforaethol y sector gofal preswyl a nyrsio 

  
Yn fwy diweddar, rwyf hefyd wedi derbyn e\-bost gan Elaine Lorimer, Prif Weithredwr Comisiwn y Gyfraith, yn fy hysbysu bod Comisiwn y Gyfraith yn cytuno bod yr adroddiad annibynnol wedi codi materion difrifol iawn, a bod Comisiwn y Gyfraith ar y Deuddegfed Raglen Diwygio'r Gyfraith ar hyn o bryd, a gyhoeddwyd yn 2014\. Nid yw'r rhaglen waith honno yn cynnwys prosiect penodol sy'n mynd i'r afael â'r argymhelliad yn uniongyrchol. Fodd bynnag, mae'r protocol rhwng Comisiwn y Gyfraith a Llywodraeth Cymru yn rhoi hyblygrwydd i ymateb i faterion pwysig sy'n codi y tu allan i gylch eu rhaglen. Mae Ms Lorimer wedi dweud wrthyf y byddai'n hapus i drafod ymhellach p’un a allai'r maes hwn o'r gyfraith fod yn briodol fel testun cyfeiriad ffurfiol gan Weinidogion Cymru i Gomisiwn y Gyfraith o dan adran 3(1\)(ea) o Ddeddf Comisiwn y Gyfraith 1965\.     

Casgliad  
Mae Llywodraeth Cymru yn credu y bydd gwersi pwysig i'w dysgu o hyd o'r adolygiad hwn a'r gwaith a wnaed gan Dr Flynn. Mae'r Gweinidog Iechyd a Gwasanaethau Cymdeithasol wedi ysgrifennu at bob un o'r chwe bwrdd diogelu oedolion yng Nghymru, a sefydlwyd gan y Llywodraeth hon o dan y Ddeddf Gwasanaethau Cymdeithasol a Llesiant, i ystyried yr adroddiad ac i annog ystyriaeth ranbarthol ehangach. Gofynnodd iddynt grynhoi syniadau a chamau gweithredu rhanddeiliaid ar ôl iddynt ystyried hyn, erbyn canol mis Ionawr. Mae Llywodraeth Cymru wedi awgrymu y dylid cynnal digwyddiadau rhanbarthol i helpu â'r broses hon, ac rydym wedi sicrhau bod arian ar gael gan y Llywodraeth i'w cefnogi hwy. Mae'n bleser gen i ddweud hefyd fod Dr Margaret Flynn wedi cytuno i ddod i bob un o'r digwyddiadau hyn.  
Byddaf, wrth gwrs, yn cyhoeddi'r chwe adroddiad ar wefan Llywodraeth Cymru. Yn hyn o beth, bydd y gwersi a ddysgwyd o'r digwyddiadau trasig hyn yn rhan barhaus o'r ffordd rydym yn gofalu am bobl hŷn ledled Cymru, ac yn eu cefnogi. 







Translation:


 
On July 14 I published, in full and without redaction, the independent report of Dr Margaret Flynn into cases of neglect and abuse in south east Wales that came to be known by the name of an associated police investigation, Operation Jasmine. Dr Flynn’s report detailed in an exhaustive chronology and analysis the tragedy that befell over a hundred victims and their families.  


Members will recall in the plenary session on that day how all sides of the National Assembly for Wales came together to express their sympathy with the families involved, and to commit to working together to avoid any future repeat of these terrible events.


Dr Flynn’s report contained 12 important recommendations. When I made an Oral Statement on the day of the report’s publication I committed to returning to members in this session to update you on the response of the Welsh Government. However, as the majority of the recommendations were towards organisations outside the remit of the Welsh Government I also told members on that day that I had written to the various parties involved asking for their response.


I am able therefore today to set out the response of the Welsh Government to the four recommendations directed to it or the NHS in Wales alongside those from the other relevant bodies. I have published these replies.


   

**Recommendation 1**


1\. that the residential and nursing care home sector:


(i) becomes a sector of primary national strategic importance for Wales,  recognising that low investment in the social care system means higher costs for the National Health Service and affects economic potential by failing to support a modern and trained labour force


(ii) is shaped by explicit policies to regulate and allow intervention in the social care ‘market’ to improve the quality of care by directly addressing issues such as pay and working conditions, staffing levels and the knowledge and expertise of commissioners of publicly funded services


(iii) care home managers are registered and are members of a professional body which sets professional standards, has disciplinary powers and provides them with a voice on national policy and


(iv) develops credible quality indicators to inform strategic planning for health and  

social care


  

The Welsh Government accepts this recommendation.


The Welsh Government agrees with Dr Flynn that the social care sector is of primary national significance. Not just because of the importance it has for the lives of many people, but because of its close synergy with other public services – health obviously but also housing, leisure and the range of public services.


Our Regulation and Inspection of Social Care (Wales) Bill sets out new powers for Welsh Ministers to shape the market in the way that Dr Flynn describes. The Minister for Health and Social Services is also currently researching how issues such as pay and conditions impact on the quality of services in the sector.


I believe the establishment of Social Care Wales through the Regulation and Inspection of Social Care (Wales) Bill will be the powerhouse to deliver Dr Flynn’s recommendation in relation to managers. It will maintain a register of managers, provide them with a clear career development path and offer them a forum to debate and contribute to developing ideas at all levels.  


In terms of quality indicators, the Government have set out from the beginning of this Assembly its commitment to put in place effective measurements of the impact services have on people’s lives. The national outcomes framework for people who need care and support under the Social Services and Well\-being Act sets out what well\-being means for people who need care and support and how we will measure whether well\-being is achieved. Many services will support people to achieve well\-being, this includes the residential and nursing care home sector. The outcomes framework will provide greater transparency on whether care and support services are improving well\-being outcomes for people who need care and support and carers who need support in Wales using consistent and comparable outcome indicators. This will shine a spotlight on what needs to be done to improve people’s well\-being rather than focussing on the processes involved in delivering social services.


 


**Recommendation 2**


2\. that the Welsh Government, in association with Public Health Wales, ensures that:  

(i) the significance of deep pressure ulcers is elevated to that of a notifiable condition  

(ii) senior clinicians, including Registrars, General Practitioners and Tissue Viability Nurses, assume a lead role in preventing avoidable pressure ulcers and in developing a National Wound Registry, assisted by the Welsh Wound Innovation Centre  

(iii) senior clinicians are made responsible for notifying Public Health Wales of deep pressure ulcers and  

(iv) where Public Health Wales has been informed of the existence of deep pressure ulcers, a process is identified whereby that information is communicated to the Care and Social Services Inspectorate Wales or the Healthcare Inspectorate Wales and appropriate commissioning authorities as well as to people’s families


 


The Welsh Government accepts this recommendation.


The Welsh Government will introduce a new monitoring and reporting system to record and publish incidents of avoidable pressure damage in care homes and increase the support available to address failings in the system.


A phased programme of work will be undertaken to introduce a new reporting system so that monthly incidence can be reported; this information will then be published on a public facing website. Public Health Wales will be involved in this development to ensure both its observatory function and service improvement function will be utilised in the new arrangements.


In undertaking this work it is accepted that the European Ulcer Advisory Panel definitions will be used. The new reporting system and wound registry referred to in the recommendations will therefore focus on grade 3, 4 and unstageable ulcers.  

Welsh Government accepts that in introducing this new arrangement that it adds impetus to improvements already seen as a result of the Trusted to Care (2014\) recommendations in NHS Wales.


   

**Recommendation 3**


3\. the Protection of Vulnerable Adults (POVA) process:  

(i) defines more narrowly and specifically its functions  

(ii) strengthens protective outcomes for individuals where there is an allegation or evidence that harm has occurred, by ensuring that either a care assessment or a review of that individual’s care plan is undertaken. The outcome of the process should be specific action rather than simply a determination of, for example, institutional abuse  

(iii) ensures that the NHS is accountable for fulfilling its lead responsibility for investigating such major and potentially lethal conditions as deep pressure ulcers in the residential and nursing care sector


The Welsh Government accepts this recommendation.


Through our Social Services and Well\-being (Wales) Act 2014 we are delivering a stronger framework to protect vulnerable adults which has been informed through an extensive programme of engagement and co\-production with the sector and citizens.


This work will strengthen and improve safeguarding practice, directing health boards and other relevant partners in the exercise of their duty to report adults who are suspected of experiencing or being at risk of abuse or neglect.  The conclusion of a safeguarding enquiry must be recorded in an individual’s care and support plan, including what safeguarding and associated action will be taken and by whom to deliver improved outcomes for that individual.


Revised guidance and procedures flowing from implementation of the Act in April 2016, will embed greater accountability and consistent practice by professionals at all levels across health, local authorities and the police to protect vulnerable adults and children.  This will secure appropriate and timely responses to concerns that reflect the distinct responsibilities of safeguarding partners, both individually and collectively, to lead and tackle concerns or conditions, including deep pressure ulcers.   The learning from such incidents will be utilised to inform improvement within and across organisations as part of an environment of robust, supportive challenge.        

   

**Recommendation 4**


4\. Inquests should be held, notwithstanding the fact that the deaths of Stanley Bradford, Megan Downs, Edith Evans, Ronald Jones, and others known to the Coroner, have already been registered  

  

The Coroner for Gwent, David T Bowen replied to me on 21 August. He had already had meetings with representatives of Operation Jasmine and Health and Safety Executive in order to identify a way forward. 


Mr Bowen wrote to me again on the 30 September with an update, saying he was in contact with relevant stakeholders and is now quite clear that a number of the deaths referred to in Dr Flynn’s report occurred outside his jurisdiction. Mr Bowen concludes his update by reassuring me where he does have jurisdiction, and where the law requires, inquests will be held and he is already working to that end.


   

**Recommendation 5**


5\. Gwent Police provides the families of older people in the six homes included in Operation Jasmine with the information prepared by members of the expert panel and ensures that they are supported during and after this process


Chief Constable of Gwent Police, Jeff Farrar first wrote to me on 15 July acknowledging Dr Flynn’s report and supporting the recommendation for Gwent Police to provide the families with the expert panel information. However, whilst Gwent Police held this information, Mr Farrar would need to discuss the matter with the Health and Safety Executive and the Crown Prosecution Service to ensure that it was legally appropriate to do so as the Health and Safety Executive are now in charge of the prosecution of Dr Das that is currently stayed.


On 25 September I received a second letter saying a meeting had taken place between Gwent Police, the Health and Safety Executive and the Crown Prosecution Service. Mr Farrar goes on to say in light of the pending Coroners Inquests due to be held by Mr David Bowen, HM Coroner for Gwent,  the expert witnesses may be called to provide evidence in these hearing and disclosing this information at this stage may be prejudicial to the coroners inquests.  


  

**Recommendation 6**


6\. NHS Wales considers how the responsibility for reporting hospital deaths to the Coroner is undertaken by senior clinicians and considers the need for a legal presumption in favour of reporting the deaths of residential and nursing home residents to the Coroner


  

This recommendation is directed towards NHS Wales. However, as it relates to the notification of deaths to the coroner the responsibility rests with the Ministry of Justice. I have therefore personally written to the Secretary of State to bring the Flynn Review report to his attention and to ask him for a response to this recommendation, which I will publish in due course alongside the others on our website.  


It is important to note however that since 2012 Local Health Boards in Wales have developed and introduced a process of mortality case note reviews of patients who die in acute hospitals. This process is two fold: its provides an opportunity to identify themes and areas for improvement; it also provides assurance to families that the care has been reviewed and if any concerns emerge then it is subject to a more in depth review.. Mortality reviews are currently confined in most areas to hospitals, but the intention is to extend them to cover deaths that occur in the community under the care of GPs. This process is being designed to ensure it will transition to future changes to the death certification process being brought forward by the UK Government, including the introduction of the role of Medical Examiners.  

It is important to note however that since 2012 Local Health Boards in Wales have developed and introduced a process of mortality case note reviews which aim to provide assurance when patients die in care, identifying cases where further investigation is required. Mortality reviews are currently confined in most areas to hospitals, but the intention is to extend them to cover deaths that occur in the community under the care of GPs.


As indicated previously, the majority of recommendations within the report do not fall to the Welsh Government or bodies within its powers. However I have written to all of those bodies requesting a response.


For the benefit of members however I have listed the remaining recommendations below, alongside some information on the response from the relevant bodies:


  

**Recommendation 7**


7\. General Medical Council (GMC):  

(i) collaborates with NHS Wales to identify ways in which conflicts of interest can be managed that arise from the admission of patients of General Practitioners and other GMC registrants (hospital consultants, for example) into residential and nursing homes in which such doctors are company directors, or are related to the directors of these homes  

(ii) ensures that all General Practitioners and other GMC registrants are informed about what constitutes a conflict of interest and how to manage this in practice. Given that declaring a conflict by itself would have been an inadequate safeguard given the findings of this Review, the GMC may wish to consider the specific example of clinicians owning nursing and care homes  

(iii) considers in its review of the Medical Register, the potential for recording information on declared conflicts of interest


Niall Dickson, Chief Executive of the General Medical Council, replied to me on the 24 August.


Mr Dickson stated in that letter that the General Medical Council accepts recommendation 7(i) in full and will collaborate with NHS Wales to identify what further action can be taken. He says that Dr Flynn’s report demonstrates how important it is that doctors are open and honest in declaring any potential conflicts of interest and they must never let such conflicts influence the care or treatment that patients receive.


Recommendation 7(ii) is also accepted, in principle. The General Medical Council will continue to raise doctor’s awareness of our existing guidance on financial and commercial arrangements and conflicts of interest, which is clear that doctors should declare any interests in nursing or care homes, including the interests of people close to them. Mr Dickson tells me GMC will work to develop additional resources, such as case studies, to support doctors in understanding their responsibilities in practice.


In terms of nursing and care home ownership, the General Medical Council will work with Healthcare Inspectorate Wales to explore what further effective steps could be justified, and will also work with Healthcare Inspectorate Wales to explore if there are restrictions they may wish to place.


In response to recommendation 7(iii) Mr Dickson informs me that as part of their current review of the List of Registered Medical Practitioners they are already considering including conflicts of interest on the medical register.


We will be writing to professional bodies and GP local medical committees, drawing to their attention the key messages from the report and reminding them about the management of conflict of interests (including family involvement).  All bodies and committees will be asked to take account of the recommendations and strengthen guidance about conflicts of interest as appropriate.


We will also be writing to the GMC and NHS Wales asking them to meet with Welsh Government to identify ways in which these specific conflicts of interest may be eliminated / mitigated / managed in relation to residential and nursing homes in which such doctors are company directors, or are related to the directors of these homes. In addition, we will be working closely with Care and Social Services Inspectorate Wales (CSSIW) , Healthcare Inspectorate Wales (HIW) and Health boards to consider whether any changes to regulatory legislation and / or national standards need to be considered.    


**Recommendation 8**


8\. General Medical Council (GMC) and the Nursing and Midwifery Council (NMC) consider the need for continuing reform to ensure that fitness to practise proceedings are conducted as quickly as practicable, while maintaining their primary purpose of protecting the public


With regard to recommendation 8, which is directly aimed at both the General Medical Council and the Nursing and Midwifery Council I can confirm that the General Medical Council accept this in full and have already made a commitment to reform their fitness to practise procedures by changing the way they investigate cases and streamline their adjudication processes.


On the 4 September, I received a response from Jackie Smith, Chief Executive of the Nursing and Midwifery Council, who welcomes the recommendation which reinforces their objective to take swift and fair action to deal with individuals whose integrity or ability to provide safe care is questioned, ensuring public confidence in the quality and standards of care provided by nurses and midwives.


It will also be of interest to members to note that the NMC has now concluded its disciplinary proceedings in relation to these events, and have agreed to meet with the families in the near future.


**Recommendation 9**


9\. Director of Public Prosecutions refers the Operation Jasmine Investigation to the Special Crime and Counter Terrorism Division (formerly known as the Special Crime Division) of the Crown Prosecution Service


On 31 July, I received a letter from Alison Saunders, Director of Public Prosecutions in response to Dr Flynn’s recommendation. Although Ms Saunders welcomes the publication of Dr Flynn’s report which highlights a number of issues for all agencies to consider and address going forward, Ms Saunders also states this case has previously been referred to Special Crime Division (SCD), who looked at the case review notes, and charging decisions and quality assured by an experienced lawyer from the Special Crime Division. Ms Saunders states there is no need to refer the matter again.  


**Recommendation 10**


10\. the National Police Chiefs’ Council ensures that the primacy of a police investigation delivers the ability of (a) the Care and Social Services Inspectorate Wales and (b) professional regulators, such as the GMC, the NMC and the Care Council for Wales (CCW) to take forward civil and criminal action; and address concern about alleged fitness to practise within a defined time frame


  

**Recommendation 11**


11\. the National Police Chiefs’ Council, the Health and Safety Executive, the Care and Social Services Inspectorate Wales and the professional regulators share what has been learned as a result of this Review and collaborate to specify and confirm the components of a framework for undertaking timely team and parallel action in future


I received a response on the 9 September from Chief Constable Sara Thornton Chair of the National Police Chiefs’ Council. She believes that the recommendations have, at their heart, the need for clear and effective collaboration between those who investigate serious wrong\-doing in the care sector. By its very nature, any response to these recommendations should be understood and agreed upon by all the named organisations.


For this reason, CC Thornton provided me with one single collective response setting out the progress being made. The collaboration included Neil Craig, Head of Field Operations Wales, Health \& Safety Executive, Steve Thomas, Chief Executive, Welsh Local Government Association, David Francis, Deputy Chief Inspector, Care and Social Service Inspectorate Wales, Jackie Smith, Chief Executive, Nursing and Midwifery Council, Niall Dickson, Chief Executive, General Medical Council and Rhian Williams, Chief Executive, Care Council for Wales.


In summary, the Group thought it was worth responding to the question ‘What would be different if the events that gave rise to the Flynn report happened today?’ instead of answering the recommendations directly.


CC Thornton advised me that in the ten years since the start of Operation Jasmine there have be substantial changes to the legislative framework, with significant progress in the development our collaborative frameworks. Those changes have engendered greater understanding of each other’s roles and remits; our relationships enabling collaborative working are much stronger. The group agreed to understand better how to support each others’ work to achieve the right responses and outcomes in both a proactive and timely manner in response to an incident.    

   

**Recommendation 12**


12\. the Law Commission reviews the current legal position in relation to private companies with particular relevance to the corporate governance of the residential and nursing care sector


I have also more recently, had an e\-mail from Elaine Lorimer, Chief Executive of the Law Commission, informing me that the Law Commission agrees that the independent report raised very serious issues and that the Law Commission is currently on their Twelfth Programme of Law Reform which was published in 2014\. That programme of work does not include a specific project which addresses the recommendation directly. However, the protocol between the Law Commission and the Welsh Government does allow flexibility to respond to pressing issues that emerge outside the cycle of their programme. Ms Lorimer has indicated to me that she would happily discuss further whether this area of law might be appropriate as the subject of a formal reference by Welsh Ministers to the Law Commission under section 3(1\)(ea) of the Law Commissions Act 1965\.     


Conclusion The Welsh Government believes there will continue to be significant learning from this review and the work that Dr Flynn undertook. The Minister for Health and Social Services has written to each of the Welsh six adult safeguarding boards that this Government established in Wales under the Social Services and Well\-being Act to consider the report, and to facilitate a wider regional consideration. He has asked them to bring together the thoughts and actions of stakeholders following that consideration by the middle of January. The Welsh Government has suggested regional events to help this process, and we have made available Government money to support them. I am also pleased to say that Dr Margaret Flynn has agreed to attend each of these events. 


I will, of course, publish the six reports on the WG website. In this way the lessons from these tragic events will form an ongoing part of the way we care for and support older people across Wales.