What this is
The independent investigation into the care and treatment provided on Tawel Fan ward, an older people’s mental health ward at Ysbyty Glan Clwyd in Bodelwyddan, Denbighshire, commissioned by Betsi Cadwaladr University Health Board in August 2015. It was reported by Dr Androulla Johnstone of HASCAS in May 2018 as a “Lessons for Learning” report.
It examined the care of 108 patients between 2007 and 2013, following concerns raised by 23 families and an earlier external investigation. It is not a court and not a regulator’s inspection: it is an investigation commissioned by the health board that ran the ward.
What it records
The report records family allegations of “disproportionate and undignified restraint”, rough handling, unexplained bruising and patients being nursed on the floor.
It also makes a finding in its own voice: “both medication and restraint were used to manage aggression and disinhibition”.
The family accounts are counted in the report:
- four families raised improper physical restraint
- five believed relatives had been locked in their bedrooms
- three thought relatives had been confined in or by chairs
- six said relatives had been “manhandled” in a rough and undignified manner
How to read it
Start with what the numbers are. Four, five, three and six are counts of families raising a concern, out of 23. They are not counts of verified incidents, and the report records them as allegations. “Four families raised restraint” is a sentence the document supports. “Four restraints happened” is a different claim, and it is the reading this page exists to prevent.
The finding the report makes itself is the one to quote: restraint and medication were used to manage behaviour. That is a statement about practice on the ward across the period, not about any named clinician, and the report makes no finding against an individual.
The third rule is specific to dementia care. The restraint here is mostly not a hold. It is the chair, the lap belt, the locked bedroom door and the sedative, which is why the report’s phrase “disproportionate and undignified” is the finding families recognise and the one a record has to capture. A page about physical intervention alone would miss most of what was described.
Where it stops
One ward, one health board, 108 patients, 2007 to 2013. The ward closed in 2013 and the board was placed in special measures; the report is evidence about practice in that period, and nothing in it describes the board as it is now.
It is an investigation, so it makes recommendations and findings about care, not determinations of liability. It does not establish a death and does not assess whether any individual’s care caused harm. The record flags a medium naming risk, which is why no patient, relative or member of staff is identified here.
The evidence base is a single source, the health board’s hosting of the full report, so confidence is probable rather than confirmed: the report was opened and read in part, but there is no second independent publisher of the text.
Sources
Where restraint in a dementia service is being reviewed, our restraint reduction training covers the chair, the belt and the sedative as restraint, and how to record each one.
Reviewed 20 October 2026.