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Adult Mental Health: Betsi Cadwaladr University Health Board

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Adult Mental Health


Upheld in whole or in part

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Non-public interest report issued: complaint upheld

Relevant body

Betsi Cadwaladr University Health Board

Ms C’s complaints centred around the management and care she received from the local community mental health team (“the CMHT”) of Betsi Cadwaladr University Health Board (“the Health Board”). These included:

(a) Mostly being “bounced” between primary (lower tier support/care) and secondary (more specialised support) care or referred to services that were unsuitable due to her complex needs over the last 2 years.

(b) The lack of a care co-ordinator and care plan when under the CMHT.

(c) Poor communication and care planning.

(d) The assessments that were carried out have related to the suitability of services rather than Ms C’s needs.

(e) The quality and nature of the support provided had not been “person centred”.

(f) The “profound lack of seamless continuity of care” in the care provided.

(g) Inadequacies around the monitoring and prescribing of medication to address Ms C’s mental health concerns.

(h) The lack of support to address Ms C’s pica eating disorder, which relates to eating unsuitable substances, which in Ms C’s case is hard plastic, given the health implications for her.

(i) Poor complaint handling and complaint response both at a service level and corporately.

Ms C complaints in relation to (a) – (f) and (i) were upheld to varying extents. The Ombudsman’s investigation found that following Ms C’s self-referrals she was appropriately referred to primary care. However, it was identified at various stages of her care that assessments could have been better and that there was a lack of documentation around the multidisciplinary team (“MDT”) decision-making. This meant it was not possible to be wholly confident in the robustness of the decision-making process in Ms C’s case. At a primary care level, the investigation found shortcomings around the planning, co-ordination and continuity of care meant that the initial care she received was fragmented, unsatisfactory and not person centred. Ineffective communication between June and November 2020 was also identified as an issue. There were also shortcomings in the Health Board’s handling of Ms C’s complaint as it was identified that more could have been done to provide a robust response, given the Ombudsman’s findings around CPN assessments and MDT documentation. The investigation found that the failings identified, had caused Ms C an injustice and this ranged from her needs not being as fully addressed as they should have been, to Ms C having to complain further to get answers.

Ms C’s complaint about her medication was not upheld as medication had been prescribed and reviewed appropriately. In terms of her pica the Ombudsman’s investigation concluded that her management was in keeping with accepted clinical management and did not uphold this part of Ms C’s complaint.

The Ombudsman’s recommendations included the Health Board apologising to Ms C, documenting MDT discussions if it did not already do so and reminding community psychiatric nurses in the CMHT to consider housing and well-being as part of their assessment process.