The report highlights power outages in critical care, low staff morale, senior staff bickering and poor behaviour not being tackled
13:13, 07 Aug 2026Updated 15:04, 07 Aug 2026
An independent report into Cardiff and Vale University Health Board has been published(Image: Media Wales)
The full details of an investigation raising major concerns about governance, culture and leadership at a trouble-hit Welsh health board have been published.
An independent investigation into Cardiff and Vale University Health Board reveals staff say the the poor condition of buildings is compromising their ability to deliver safe care, morale is low, concerns are not being taken seriously, and bickering among top level executives.
Staff also directed criticisms at the Welsh NHS, saying the failure to update computer systems had led to problems including a piece of paper posted under a door resulted in a patient lost to follow up with a missed reported diagnostic test.
The full report has been published by NHS Wales after WalesOnline revealed that the investigation had concluded and had found “severe operational and leadership failings”.
NHS Wales commissioned the investigation after the Welsh Government put the health board, which runs the troubled University Hospital of Wales, in level four intervention – one below special measures.
Among the concerns highlighted in the report were a reluctance from managers to address poor behaviour, a lack of confidence that escalating issues would be addressed and how a lack of digitalisation has led to missed diagnoses.
The two independent advisors who produced the report also heard morale frequently described as the “worst it has ever been”, and found that the last two years had seen an “excessive” number of Never Events – serious incidents that are wholly preventable. For the biggest stories in Wales first sign up to our daily newsletter here.
The investigation also highlighted how staff said the poor condition of the health board’s buildings was compromising their ability to deliver safe care. In 12 months there were four power outages in critical care, flooding in the outpatient department, and cancelled appointments as a result.
Here are the key findings of the report:
Staff repeatedly said the health board and Wales was behind the rest of the United Kingdom in several areas e.g. the use of advanced practice; adopting different models of care; tolerating poor behaviours; embracing change.Managers and medical staff repeatedly said the NHS Wales Joint Commissioning Committee (JCC) was not appropriately financially supporting national services that take place in the health board.Since Covid-19, the health board has been fulfilling an increased number of services which were transferred from other health boards and not subsequently returned.This means the health board has continued delivering services with perceived inadequate financial remuneration. The report found that the pandemic also led to many people retiring which meant others were rapidly promoted despite inexperience, and a subsequent skills gap is still evident.There is a reluctance from managers to apply HR policy in tackling poor behaviour/conduct for fear of grievance. There is therefore a limited confidence that escalation of issues would be addressed and the phrase ‘oh that’s just xx’ was often the response particularly if the issue related to a senior member of staff.The current physical estate of the health board is in poor condition. In places it is substandard and is the source of significant frustration for many staff who said they feel undervalued and feel their ability to deliver safe care is compromised.The independent advisors heard they had been four power outages in 12 months in critical care, flooding in the outpatient department and cancelled appointments. They said this was the result of over 10 years of underinvestment in maintenance and the upgrading of buildings.The “Digitalisation of the NHS in Wales lags behind comparable national health care systems elsewhere”, staff said. There was evidence of at least one manual process where a piece of paper posted under a door resulted in a patient lost to follow up with a missed reported diagnostic test.There was a predominant sense that the health board is a money-centric organisation focused on the acute hospital to the detriment of a whole system integrated approach.There is a pervasive culture of learned helplessness and a lack of pace and urgency even when confronted with serious issues. Staff reported feeling demoralised and demotivated with a need for hope, positive direction and a renewed sense of purpose. Morale was frequently reported as the “worst it has ever been”.There are poor team dynamics overall in the organisation leading to competition for resources.In the last two years there has been an excessive number of never events reported within the board. Afterwards such events there is an absence of these being used for learning and to take corrective action to prevent further never events. Never events are defined as serious incidents that are wholly preventable because guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and should have been implemented by all healthcare providers.Frequent reports of the executive team ‘bickering’ in front of other senior leaders means many managers perceive the team to be split in two rather than being a team.Many staff members have never worked in another hospital or healthcare system meaning they only have one point of reference.
Chris Bown, Interim Chief Executive of Cardiff and Vale University Health Board, said: “We take the findings of the report extremely seriously and recognise that there are a number of areas requiring improvement – these must be addressed at pace.
“Whilst work is already underway in a number of the areas identified, we recognise that more needs to be done.”
Mabon ap Gwynfor MS, Cabinet Minister for Health and Care, said the concerns raised were unacceptable and need to be urgently addressed.
He continued: “The report is clear that the health board’s challenges are systemic and long-standing, requiring organisational reset, a single recovery plan, stronger accountability, assurance and cultural change. Under this new Welsh Government, we will not allow such issues to continue, and we will robustly hold the health board to account for its performance.
“I expect the health board to work closely with NHS Wales Performance and Improvement to develop and deliver a single organisation-wide improvement plan that responds to the recommendations, addresses the underlying causes of concern, and sets out clear actions, milestones and strengthened accountability arrangements aligned to the escalation framework and de-escalation criteria.”