Ms C complained about the care and treatment provided to Mr B by the Health Board’s mental health services between 6 July and 7November 2022. Specifically, the investigation considered whether the care and treatment provided to Mr B in the community between 6 July and 22 September 2022 was clinically appropriate. It also considered whether the care and treatment provided to Mr B during his admission to hospital, including the arrangements for his discharge, between 23 September and 7 November 2022 was clinically appropriate.
The Ombudsman found that Mr B’s care and treatment in the community between 6 July and 22 September was clinically appropriate. Mr B received appropriate assessments and input. There was no evidence that a lack of care and treatment in the community setting resulted in Mr B’s deterioration or his admission to hospital on 23 August. This complaint was not upheld.
The investigation found that, following the hospital admission, appropriate care and treatment had been provided in respect of physical assessments, occupational therapy and meeting Mr B’s basic needs. However, it was not clear what arrangements were made for Mr B to have a follow-up a Magnetic Resonance Imaging scan (“MRI”- the use of strong magnetic fields and radio waves to produce detailed images of the inside of the body) that was indicated as being needed after discharge. Cognitive test results for Mr B during admission were also not appropriately followed up. The evidence for Mr B’s diagnosis was lacking, and a rationale for the diagnosis was not clearly stated either. Other possibilities were not appropriately explored. This called into question the rationale put forward for Mr B’s discharge. The documentation available was inadequate to demonstrate how safety was to be maintained within the temporary home upon discharge. Ms C was not informed of where Mr B was to be discharged, and he did not receive the input of a care co-ordinator to facilitate the transition. This complaint was upheld.
The Ombudsman recommended that the Health Board apologise for the failings identified and bring the investigation findings to the attention of the clinicians involved in Mr B’s treatment and diagnosis. She also recommended that the Health Board remind clinicians and ward staff of their obligations in regard to: recording rationale for diagnoses; updating risk assessments with sufficient detail tenable transfer of care; ensuring appropriate communication about discharge arrangements with next of kin, and; ensuring cognitive and physical investigations are followed through when identified as being needed.