Ms A (anonymised) made a complaint, to the Ombudsman, about the care she received from Cardiff and Vale University Health Board.

She was detained in Wales under the Mental Health Act but later moved to a secure hospital in England to be closer to her family and to allow an easier step-down into the community where she wished to live.  The Welsh health board funded her placement in a rehabilitation unit in England.

Ms A was discharged from detention in March 2016.  However, she agreed to remain as an informal (voluntary) patient in the rehabilitation unit until aftercare and supported living accommodation were put in place.

The Ombudsman found that she encountered a “Catch 22” situation.  The Community Mental Health Team (CMHT) in England would not accept a referral from the Health Board until Ms A was registered with a local GP, discharged from the Hospital and living at a local residential address.  However, the supported living providers would not accept a referral to assess Ms A for placement without prior local CMHT input.

As a result, Ms A remained an inpatient at the Hospital for almost a year after her discharge from detention, on a locked rehabilitation ward with other patients detained under the Mental Health Act. In that time, she reported being physically attacked by other patients.

The Public Services Ombudsman for Wales and the Parliamentary and Health Service Ombudsman have written to the Cabinet Secretary for Health and Social Services in Wales and the Secretary of State for Health and Social Care to raise the issue of cross border care.


Commenting on the report, Public Services Ombudsman for Wales, Nick Bennett, said:

“I find it particularly disheartening that Ms A was significantly let down by health services at a pivotal time in her mental health recovery.  She remained on a locked rehabilitation ward with detained patients when she should have been progressing with her recovery and establishing her independence.  This unacceptable situation continued for almost a year.

 “She was targeted by other patients, during her stay as an informal patient, and sadly the Health Board failed to provide her with a safe environment during this period.  I believe Ms A’s human rights were compromised by the failings identified.

“I am concerned by the “Catch-22” situation and the systemic issues identified in my report.  I have shared a copy with the Welsh Government, so it can review whether action needs to be taken at an all-Wales level to improve arrangements for cross-border mental health treatment.”

Parliamentary and Health Service Ombudsman, Rob Behrens, said:

“Keeping someone detained for reasons of bureaucracy is a breach of human rights and shows a complete lack of care.

“The NHS in England and Wales must work together to produce joint guidance on supporting vulnerable mental health patients who transfer from one country to another in the UK, to ensure this does not happen again.”

The Health Board has agreed to a number of recommendations, including providing a written apology to Ms A for the failings identified.