Report Date


Case Against

Betsi Cadwaladr University Health Board


Adult Mental Health

Case Reference Number



Early resolution

Miss D complained about the care provided to her by Betsi Cadwaladr University Health Board in relation to her mental health and wellbeing, particularly in the context of her diagnosis of Functional Neurological Disorder (“FND”). Miss D said that the Health Board failed to seek or understand her diagnosis, provide appropriate access to psychological interventions or provide ongoing and crisis mental health support.

The Health Board’s investigation report of 23 May 2023 confirmed that it had failed to provide her with access to psychological input, and that staffing issues had resulted in her receiving disjointed care that fell below an appropriate standard. The Health Board wrote to Miss D on 23 June to offer apologies for those shortcomings; it noted that Miss D was now receiving appropriate support and psychological intervention, and said that the complaint would be shared anonymously with staff for learning. Miss D said that she wanted to see details of what action was planned (or had been taken) to prevent recurrence, especially around staffing shortfalls, availability of support and services, communication with patients, and the understanding of FND from a mental health perspective.

The Health Board agreed to do the following within 6 weeks of the Ombudsman’s final decision notice:
• Issue a formal reminder to all relevant staff on the importance of ensuring consistent and effective communication with patients.
• Draft an accompanying notification to be included with the anonymised complaint, highlighting the importance of establishing the nature of any input from other relevant specialists involved in a patient’s care to ensure the patient’s needs are being met.
• Outline the actions taken to improve staffing within the department and confirm current staffing capacity.
• Consider whether formal training around FND was necessary for Mental Health Staff.
• Write to Miss D to reiterate its apologies for the inconsistencies and shortcomings in care provision, detail how the actions above have been completed and note any positive outcomes from them.