Report Date


Case Against

Swansea Bay University Health Board


Adult Mental Health

Case Reference Number



Upheld in whole or in part

Ms A complained about the standard of treatment provided to her by Swansea Bay University Health Board’s (“the Health Board”) Community Mental Health Team (“CMHT”). In particular, Ms A said that the Health Board failed to:

• Provide regular home appointments for depot injections (for slow-release administration of antipsychotic drugs) after May 2021.
• Provide support and monitoring when she had to stop taking her regular lithium medication (a drug for treatment of mood disorders) in December 2021.

• Identify and act on matters raised at physical health checks.
The Ombudsman found that there were shortcomings in the care provided to Ms A. Her care plan clearly identified regular home visits for injections, and these were not always arranged in advance and sometimes did not occur. She also noted that the support and monitoring provided to Ms A when she was advised to stop taking lithium was not adequate, and Ms A’s mental health was not monitored. Both these aspects of the complaint were upheld.

The Ombudsman did not identify any failings in relation to the physical health checks and did not uphold this aspect of the complaint.
The Ombudsman also noted that some significant clinical entries were made in the handwritten records and not recorded on the CMHT electronic system. Therefore clinically significant decisions and changes were not accessible by all clinicians involved in a patient’s care.

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The Ombudsman recommended that the Health Board should (within 1 month) apologise in writing to Ms A for the identified shortcomings in her care. She further recommended that the Health Board should (within 3 months):

• Ensure that all relevant CMHT clinic entries and prescribing advice and decisions should be included in the electronic patient records

• Review the individual responsibilities, set out in its Lithium Prescribing and Monitoring Protocol, between primary and secondary care to ensure that these are being met. This should include how any changes to medication should be communicated between secondary and primary care.
16 May 2023