All health boards 'must learn lessons' from Betsi Cadwaladr failings
Health boards across the country must learn lessons from failings at Wales' largest health board, assembly members have warned.
Some senior managers at Betsi Cadwaladr in north Wales have already stepped down after an earlier critical report.
The assembly's public accounts committee says the new leadership now faces a "huge task".
It found the management of a C. diff outbreak and infection control "extremely concerning".
The committee examined the under reporting of serious incidents involving Clostridium difficile (C. diff) at Glan Clwyd Hospital - which had 96 cases in five months earlier this year - and had first been revealed in an earlier report.
The committee found "inadequate and inaccurate" information had been provided to board management about the infection.
The former board chairman told the AMs he was "shocked" to hear of the outbreak later than he should have been told.
The board has already issued an apology over the outbreak.
The committee made 21 recommendations to the Welsh government into wider lessons after its investigation into Betsi Cadwaladr.
- Strengthening performance and accountability for chairs and chief executives of all NHS bodies in Wales
- Developing a new national training programme for all members serving on NHS health boards in Wales
- Calls on the Welsh government to review how it checks data on patient safety and quality of care, to ensure it is correct
- Makes public details of rises in deaths at Welsh hospitals, known as 'Rise in Risk Adjusted Mortality Index' or Rami
The joint report published in the summer by the Healthcare Inspectorate Wales (HIW) and the Wales Audit Office (WAO) flagged up a number of serious concerns about the way Betsi Cadwaladr was run.
The health board is the largest NHS organisation in Wales, with its three main hospitals at Gwynedd hospital in Bangor, Glan Clwyd in Denbighshire, and at Wrexham Maelor.
As well as management failings over C. diff, the joint report had also pinpointed financial problems, with managers avoiding overspend by delaying operations and letting waiting lists increase.
A breakdown in the working relationship between the then board chair, Prof Merfyn Jones, and the chief executive, Mary Burrows, was also highlighted.
After the findings were published, Prof Jones announced he was standing down from his position, and was replaced in September by Dr Peter Higson, a former chief executive of the HIW.
Mrs Burrows also said she intended to leave but a final financial settlement has yet to be agreed.
The report authors said the delay in the settlement process had "significantly impeded the health board's ability to progress forward".
AMs have also focused on an increase in unexpected deaths at the health board's three hospitals over the last year, leading to increased Rami scores.
The committee said it now wanted the Betsi Cadwaladr board to make findings of its own investigations into the issue public - and for the Welsh government to make Rami figures for all hospitals available.
Publishing the report, the committee's chair Darren Millar AM said: "The incoming leadership team at Betsi Cadwaladr University Health Board has a huge task ahead.
"It needs to urgently restore public confidence whilst establishing a new, robust and accountable governance system that addresses the gap between the board and the ward.
"The failings highlighted by our inquiry, along with those in the joint report from the Wales Audit Office and Health Inspectorate Wales, are particularly troubling as they come at a time when the entire health sector in Wales is going through seismic changes in both funding and structure."
He said they believed the Welsh government should ensure that all health boards learn from what happened in north Wales to prevent a repeat.
Dr Higson, the new chairman of the Betsi Cadwaladr Health Board, said report would be considered carefully adding that moves were being made to improve processes.
"We have already accepted that there have been failings, which we are working to put right," he said.
He said the safety of patients "is what matters most and infection control is a top priority".
A Welsh government spokesperson said it would consider the findings in detail.
"It highlights areas that need to be strengthened and work on these has already started," said the spokesperson.