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Adult Mental Health: Betsi Cadwaladr University Health Board

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Adult Mental Health


Not Upheld

Case ref number


Report type

Non-public interest report issued: complaint not upheld

Relevant body

Betsi Cadwaladr University Health Board

Ms Y’s Advocate (“the Advocate”) complained on her behalf about the care Ms Y received at the Wrexham Maelor Hospital and the Glan Clwyd Hospital.
We investigated whether:
• between 24 December 2020 and 13 January 2021, it was reasonable that Ms Y was without medication that may have prevented her from having psychotic episodes.
• At Ms Y’s discharge on 13 January 2021, her eating and sleeping issues, and the “red flag” that she intended to go to the railway station, were appropriately considered.
The Ombudsman’s investigation found that the withdrawal of Ms Y’s antipsychotic medication was appropriate. Ms Y had declined some medications on several occasions rather than medications not being prescribed or withheld, but this did not have a significant effect on her health. It was found that the withdrawal of medication had not resulted in clinical deterioration for Ms Y; and she exhibited no symptoms associated with psychotic illness and their withdrawal did not appear to have caused her to suffer hallucinations. This aspect of the complaint was not upheld.
It was also found that Ms Y’s eating and sleeping issues were considered and, at the time of her discharge on 13 January 2021, Ms Y and the clinical team were of the view that she had improved. Ms Y’s “red flag” that she intended going to a railway station was considered to be a non-specific comment and she was appropriately assessed as not having a clear risk of suicide. This aspect of the complaint was also not upheld.