Mrs B’s complaint centred on whether the care and treatment for depression and anxiety provided to her husband, Mr B, by the Princess of Wales Hospital between 6 and 15 September 2023 was clinically appropriate. In particular, whether action taken to risk assess, explain side effects of medication and the level of contact with professionals was adequate. Mr B committed suicide on 16 September.
The Ombudsman’s investigation found that although there were aspects of the assessment that was carried out on Mr B on 6 September that were in keeping with relevant guidance in terms of the treatment offered, there were clinical shortcomings in the process. This included issues around patient discussion of the medication plan and the side effects, Mr B’s risk assessment, collaboratively working with the GP and the information provided to the GP. There were also clinical and administrative shortcomings in relation to the telephone contact with Mr B on 15 September, with no documented evidence of a risk assessment being completed by the Psychiatric Doctor despite Mr B’s reference to “not coping”.
The investigation concluded that even if the clinical failings identified had not occurred this did not mean that the decisions around medication and discharging Mr B back to his GP care would have changed or that Mr B’s management would have been any different. However, there remained a possibility that decision making may have been different and this represented an injustice for Mrs B and her family who have to live with the uncertainty of not knowing whether the sad outcome in relation to Mr B might have been different but for the clinical failings identified. Therefore, it was to this extent that Mrs B’s complaint was upheld.
The Health Board accepted the Ombudsman’s recommendations which included an apology to Mrs B for the failings identified in the report and learning and process changes including improved documentation and better risk assessments. The Health Board also agreed to carry out a follow-up audit and an action plan to address any issues that might be identified.
