Terms of reference

In 2016, Kris Wade (KW) was convicted of the murder of Christine James. At the time of the offence, KW was employed by ABMUHB as a care assistant, but had already been suspended from work pending the investigation of three separate sexual assault allegations made against him by individual patients. He worked in a learning disabilities setting run by ABMUHB.

ABMUHB undertook an internal review looking into the management of KW’s employment and the handling of the three separate allegations made against him. This was an internal, desktop review, undertaken by senior individuals within ABMUHB who were independent of the Learning Disability directorate. 

ABMUHB’s internal review identified a number of significant issues of concern and procedural weaknesses relating to governance, recruitment, adult safeguarding, incident reporting and culture within ABMUHB. It highlighted several areas for learning and improvement. An improvement plan outlining actions taken to date has been published alongside the report. ABMUHB’s review concluded that KW’s future conduct and behaviour outside of his employment could not have been predicted or prevented.

In order to be satisfied that appropriate actions had been identified by ABMUHB and that its action plan for improvement is sufficiently robust, Welsh Government has asked HIW to undertake an independent assessment to determine whether the learning and actions as a result of that review were appropriate. 

In requesting the review, Welsh Government suggested a number of broad parameters. HIW has taken time to consider these views and the views of others in order to develop its own terms of reference for the independent review. This consisted of initial consideration of the documentary evidence on which ABMUHB’s review was based, and inviting discussions with other interested parties. 

Our review methodology will consist of thorough examination and analysis of the documentary evidence. We will also collect evidence from interviews. There will be discussion and engagement with other key individuals throughout the process, and independent professional input from peer reviewers. 

It is anticipated that this review will be concluded by December 2018. A report will be published at the end of the review process.

Sources of information to inform the HIW review  

In order to ensure a robust and independent review, HIW will consider a wide range of information and evidence. During the course of the review, we will:

• Speak with key stakeholders and other interested parties
• Interview relevant individuals
• Examine and analyse documentation held by ABMUHB, and other key stakeholders, pertinent to the review
• Obtain input from relevant independent peer reviewers
• Produce a public report at the end of the review detailing HIW’s findings. 

What the review will consider 

The independent review will determine whether:

• ABMUHB’s internal review was sufficiently thorough
• ABMUHB’s conclusions were appropriate on the basis of the evidence considered
• The action that ABMUHB has taken in light of those conclusions is adequate to ensure patient safety
• Additional or different conclusions should be reached on the basis of additional evidence considered during this review
• There is any wider additional learning for the NHS in Wales.

The areas and processes within ABMUHB that HIW will be considering in relation to this case include:

• Staff recruitment and employment
• Incident reporting
• Adult safeguarding
• Governance and culture

What the review will not consider

The decisions or actions of the Police or Crown Prosecution Service will not form part of this review. This is not within the remit of HIW as it is only able to investigate matters in connection with the provision of healthcare services. However, we will be seeking the co-operation of and information from South Wales Police which may assist us in our consideration of ABMUHB’s actions.