Mihangel ap Dafydd

Dear Mr Layton, Thank you for your email of 3 May to Acting Chief Medical Officer, enclosing your Regulation 28 report following the death of Mihangel ap Dafydd at Morlais Ward, West Wales General Hospital, Glangwilli. I am replying in my role as the lead official for NHS estates and facilities issues within Welsh Government. I note your report and requested actions have been sent to the Chief Executive of Hywel Dda University Health Board. However, given that you have identified issues which are of relevance to all NHS organisations, I can confirm that we will be issuing an addendum to Health Building Note 35 – “Accommodation for People with Mental Illness Part 1: The Acute Unit Ligature Free Design”. This addendum will specifically highlight the requirement for ligature free design in both new and existing acute mental health unit facilities in Wales. The addendum to the Health Building Note will also widen the requirements to other facilities dealing with acute mental health in-patients including Children & Adolescent Mental Health Services (CAMHS). This document is in the process of being finalised by Welsh Government officials and our NHS estates advisors and will issue by the end of this month. In addition to the above, I have also requested that NHS Shared Services Partnership – Specialist Estate Services (NWSSP-SES) undertake a formal review of HBN 35. This will consider if the HBN needs more substantial amendment or if it should be superseded by a revised HBN 03-01, amended, where required, to reflect further developments in Welsh Government policy and any specific needs of NHS Wales. Val Whiting Dirprwy Gyfarwyddwr, Cyfalaf, Ystadau a Cyfleusterau/ Deputy Director, Capital, Estates & Facilities

2 I will pick up the individual circumstances and actions taken by Hywel Dda University Health Board at Glangwili Hospital when I next meet the Health Board later this month. I hope you find this information useful. Please do not hesitate to contact me if you have further concerns or queries.

Dear Mr Layton Re: Inquest into the death of Mihangel ap Dafydd Thank you for your letter dated the 29th April, and the Regulation 28 report for the Health Board's attention. I can confirm that the Health Board undertakes an annual point of ligature audit programme across all of its mental health and learning disability in- patient units, which includes an audit of Morlais Ward on the West Wales General Hospital site The point of ligature audits undertaken following Mr. ap Dafydd's death identified potential point of ligature risks with windows on number of the in-patient units, including Morlais Ward which were reported through the Health Board'$ Capital programme: The point of ligature programme is considered alongside all of the annual priorities across the Health Board, and the replacement of windows was not deemed to be the greatest priority, as following identification of the risk, steps were taken to mitigate the risk, including the securing of windows in some areas. The point of ligature audit programme plans to repeat the audit of all inpatient units across mental health and learning disabilities in May/June 2016. Following which a prioritised recommendations will be submitted for consideration by the 2016/17 Capital programme, for each unit considering Swyddfeyda Corlforaethol, Adeilad Ystwyth, Corporate Offices Ystvyth Building Cadeirydd Chair Hafan Derwen, Parc Dewi Sart; Heol Ffyrnon Job, Hafan Derven St Davids Pamk, Jcb's Well Road Mrs Bernardine Rees OBE Caeryradin, Sir Gacrfyrdcin; SA31 3BB Cammarthcn, Carmarlhenshire, SA3I 3BB Prif Weithredwr Chiei Executive Mr Steve Moore 7

replacement, repair adaptation of the existing windows in line with the Department of Health Building Note 03-01. Whilst the programme of work is being developed and prioritised it is essential that the inpatient units that require adaptations to windows are able to provide a safe and therapeutic environment for patients. Ensuring patient dignity and safety are priority the Mental Health and Learning Disabilities Directorate_ During the programme of work that will be undertaken, inpatient areas will continue to be subject to regular environmental risk assessment; Where necessary, actions will be taken to mitigate risks that take into consideration patient dignity and comfort