Miss A complained about the care and treatment provided while she was a voluntary inpatient at a mental health services unit under the Health Board. The investigation considered whether appropriate care and treatment was provided under the care of the First Consultant Psychiatrist, between May and August 2025, particularly in relation to consideration of appropriate medications and assessment of Miss A’s capacity.
The Ombudsman found that Miss A’s care and general management from the First Consultant Psychiatrist was appropriate overall, including prescribing of medication. However, the investigation found that a further capacity assessment should have been carried out when Miss A discharged herself from a hospital to return the unit without receiving appropriate wound treatment, against a surgeon’s advice, on 10 July. It is not possible to know for sure whether that further capacity assessment would have resulted in Miss A being considered to have lacked capacity for decision making around her wound care and treatment, and whether she would then have been able to receive treatment sooner, against her wishes. However, this uncertainty is an injustice to Miss A and to that extent the complaint was upheld.
The Health Board accepted the Ombudsman’s recommendations to provide Miss A with a written apology for the failings identified; to share the Ombudsman’s report with the First Consultant Psychiatrist for the purposes of reflection and learning at their next annual appraisal; and to share the report with the multidisciplinary team staff involved in Miss A’s care during the period that was investigated so that they can reflect on the findings.