The Welsh Government is demanding that a problem-plagued health board makes further improvements to services following the publication of a report into the closure of a hospital ward for dementia patients.
Health Secretary Vaughan Gething said he wants Betsi Cadwaladr University Health Board in North Wales to increase the pace of improvement across a range of areas.
The Tawel Fan ward at Glan Clwyd hospital, Denbighshire was closed in December 2013 and an inquiry in 2015 uncovered "institutional abuse".
Mr Gething said the report by the independent Health and Social Care Advisory Service did not substantiate previous claims of institutional abuse or neglect but did highlight failings of governance that have compromised care.
"This report is the result of a very extensive and thorough investigation into the care and treatment provided to patients on the Tawel Fan Ward of the Ablett Unit at Ysbyty Glan Clwyd," he said.
"Whilst the report does provide the very important reassurance that they could not substantiate previous claims of institutional abuse or neglect, it does reinforce wider failings within the health board.
"It highlights the need for more rapid attention to secure improvements across a range of areas, whilst recognising that some of that work is already under way.
"Overall, the report makes it very clear there is still some way for the health board to go and this will require further focused oversight under the special measures arrangements."
Mr Gething also urged caution about jumping to conclusions about the apparent contradiction in the conclusions of the investigation and some earlier reports.
"The investigation had a much wider remit and unlike the previous report, was able to access a comprehensive set of documentation, including clinical records, and draw in specific mental health expertise," he said.
"This is a very substantial report that warrants further careful reading and consideration. I will be discussing the report with the health board and responding more fully in due course.
"Whilst this will be a very difficult day for both families and staff of Betsi Cadwaladr University Health Board who were involved or affected by the investigation, I would hope that these findings can act as a catalyst to the lifting of a dark shadow that has extended over mental health services in North Wales for a number of years."
The 2015 inquiry by health specialist Donna Ockenden found there were regimes and routines on the ward which may have violated the human rights of patients.
But North Wales Police has decided in conjunction with the Crown Prosecution Service not to bring criminal charges in the case.
The health board's chief executive was later suspended and the organisation placed into special measures.
In a joint statement, Dr Peter Higson, chairman of the health board, and its chief executive Gary Doherty said: "We fully acknowledge that this has been and will continue to be a very difficult process for all the families and staff involved.
"The independent investigation has taken over two years, but it is vital that it had the time, scale and scope to produce the full and definitive account of what happened, as well as a detailed context of the situation across Betsi Cadwaladr at the time.
"Today's report provides us with a full, evidence-based view that is the result of a comprehensive investigative process which included over 100 interviews of families and staff and over half a million pages of information including police transcripts, medical records, staff records and corporate records.
"The investigation found the overall standard of care on the ward to be generally good and found no evidence to support the view that patients suffered from deliberate abuse or wilful neglect.
"However, it found that some patients did not receive the standard of care that we would expect across our services.
"The report has also highlighted systemic organisational weaknesses that were present at that time which contributed to poor care.
"Since 2013, there have been substantial improvements to the way the health board is organised and operates, as well as work to improve the involvement of families and carers, provide better services for people with dementia and the strengthening of our safeguarding arrangements.
"However, we are clear that we have much more to do to make improvements across all of our adult services - not just mental health services."
Donna Hutton, head of health at Unison Cymru Wales, said: "The health board must focus on ensuring this can never happen again and this means allowing the investigation to be completed in a thorough and fair manner.
"We appreciate the effect the length of the process has had on the families, but it is important to get this right.
"The overwhelming view of Betsi Cadwaladr healthcare workers is their determination to get on with caring."
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