Report Date


Case Against

Cwm Taf Morgannwg University Health Board


Appointments/admissions/discharge and transfer procedures

Case Reference Number



Not Upheld

Ms D complained, on behalf of her late father, Mr F, that following his emergency admission to the Royal Glamorgan Hospital after taking an overdose of medication and developing breathing difficulties, he was inappropriately and prematurely discharged. Ms D complained that:

1.Despite a longstanding history of mental health problems, Mr F was discharged without any prior coordination/liaison with community mental health services.

2.On discharge, Mr F (who lived alone) was breathless, weak, virtually blind and unable to stand or mobilise unaided. Despite this, he was discharged without a home-care support package in place.

3.These failings contributed to Mr F’s subsequent deterioration and may have influenced his decision (made within 2 weeks of discharge) to end his life by means of a further medication overdose.

The Ombudsman did not uphold Ms D’s complaints. With regard to complaint 1, the Ombudsman, via her Advisers, identified that there was a failure by hospital clinicians to liaise with community mental health services prior to Mr F’s discharge. However, there was no evidence (in this instance) that this communication failing gave rise to any adverse consequence.

With regard to complaint 2, the Ombudsman was unable to reconcile Ms D’s description of her father’s condition with the available documented evidence. She found that that, on the day of discharge, all of the clinical and functional indicators of Mr F’s fitness for discharge were in place and that there was no clinical basis for preventing or delaying it. She also found that some of the coping-difficulties that Mr F subsequently faced (as identified by the family) were, in part, related to his decision to decline and/or minimise the available home support that clinicians offered.

Finally, the Ombudsman found no evidence to support the complaint that the tragic outcome of Mr F’s subsequent, post-discharge psychological deterioration – and his decision to end his life some 2 weeks after discharge – can be attributed in whole or in part to any failings of care. The Ombudsman found that Mr F received an appropriate level of support from his CPN and there was no evidence that, following discharge, he suffered any crisis of mental health, or intensification of depression, or that he or the family made any request for intervention and/or support that was overlooked or not responded to. Mr F was seen by his CPN 2 days prior to his decision to end his life and the CPN recorded that Mr F appeared to be in good spirits and explicitly stated that he had no concerns regarding his mental health.