Report Date


Case Against

Cwm Taf Morgannwg University Health Board


Adult Mental Health

Case Reference Number



Upheld in whole or in part

Mr D complained that Cwm Taf Morgannwg University Health Board (“the First Health Board”) failed to provide care and support to his late daughter, Miss E, when her mental health deteriorated during 2020. Mr D said the First Health Board failed to transfer her section 117 aftercare (free help and support following a hospital stay under the Mental Health Act delivered by the First Health Board and the local authority (“the Council”)) when she moved into a different area covered by Cardiff and Vale University Health Board (“the Second Health Board”), and did not carry out Miss E’s wishes in her care plan to continue providing care despite the move.

The Ombudsman’s investigation found that whilst Miss E had been discharged from the First Health Board’s Community Mental Health Team (“CMHT” – also made up of staff from the Council) in 2016, she was not informed of her right to self-refer back to the CMHT (within 3 years) if her mental health deteriorated, contrary to relevant guidance. This was a service failure and caused an injustice to Miss E as she did seek help from the First Health Board’s CMHT within the specified timeframe.

The Ombudsman also concluded that the transfer of Miss E’s section 117 aftercare (which ultimately did not happen) was disjointed and uncoordinated. Both the First and Second Health Boards seemed either confused or reluctant to transfer, or take on the transfer, of Miss E’s aftercare. This was a service failure that caused Miss E the injustice of being unable to access timely mental health care which would have been likely to cause her anxiety and potential distress.

Furthermore, when Miss E’s mental health deteriorated during 2020, and she sought assistance from the First Health Board, the First Health Board missed an opportunity to evaluate her and formally transfer her section 117 aftercare to the Second Health Board. When Miss E agreed to a mental health referral to the Second Health Board, but then withdrew it, it was the Ombudsman’s view that this was indicative of a worsening psychosis and should have precipitated an assessment to determine whether Miss E had capacity to make such a decision. This was the responsibility of the First Health Board and the Council, and it was an injustice to Miss E that both these bodies did not fulfil their commissioning responsibilities, especially at a time when Miss E needed it most.
Whilst the Ombudsman could not be certain whether these service failures led Miss E to take her own life, a more coordinated approach by all involved would have left Mr D reassured and convinced that everything had been done, and no stone had been left unturned in trying to get help for Miss E. This uncertainty would always be an injustice to Mr D. Accordingly, the Ombudsman upheld Mr D’s complaint.

The First Health Board agreed to implement the Ombudsman’s recommendations to apologise to Mr D, to share the report with its CMHTs, including relevant Council staff, to consider what lessons could be learnt and to report back to the Ombudsman with any improvements identified. The First Health Board also agreed to consider whether the report should be shared more widely in order to ensure there was a consistent, flexible and coordinated approach to the provision of section 117 aftercare with neighbouring health boards.