Between 2011 and 2013, three people who received care from the learning disability service made allegations of sexual abuse against Mr W.
Mr W was suspended from work in 2012 following the abuse allegations but was still an employee of the health board in 2016 when he was arrested and convicted of murdering his neighbour Christine James.
HIW was asked by Welsh Government to carry out an independent review of the health board’s actions in September 2018.
This review examined staff recruitment and employment, incident reporting, adult safeguarding, governance and culture, an assessment of ABMUHB’s desktop review, and commissioning arrangements between health boards.
It did not look at the actions of the police or the Crown Prosecution Service as this is outside HIW’s statutory remit.
Chief Executive Dr Kate Chamberlain said: “There are areas of learning within this review which are relevant to the NHS as a whole and we expect all health boards to consider our findings and recommendations.
“This case highlights the importance of safeguarding and governance processes which are essential in protecting adults at risk.
“The robustness of these processes is intrinsic to the confidence that patients and their families have in the safeguarding system as a whole.
“HIW hopes that the content and learning from this review will promote improvement in these areas, as well as highlighting the need for the new safeguarding guidance to be delivered in a timely way.”
We have published this review in full and an accompanying easyread version.