Report Date


Case Against

Aneurin Bevan University Health Board


Child and Adolecent Mental Health

Case Reference Number



Upheld in whole or in part

Mr A complained that Aneurin Bevan University Health Board failed to diagnose his daughter, B, with Attention Deficit Hyperactivity Disorder (“ADHD” – a condition that affects a person’s behaviour in terms of inattention and/or hyperactivity and impulsivity)in a timely manner as the 2 referrals that were made to the Integrated Service for Children with Additional Needs (“ISCAN”) in July 2019 and July 2020 were both incorrectly rejected.

The Ombudsman found that the first referral in July 2019, which was made by B’s GP, contained limited information and supporting documentation. She concluded that, although B could have possibly been assessed after this referral, it was nevertheless within the range of a reasonable clinical decision that the referral was not accepted on this occasion. However, the Ombudsman found that the second referral in July 2020 should have been accepted, as ADHD features were clearer in the documentation and B met all the criteria from the referral checklist. After Mr A made a complaint to the Health Board, B was assessed by a Neurodevelopment Nurse and Child Psychiatrist, and a diagnosis of ADHD was subsequently reached. The Ombudsman concluded that there was a delay of at least 6 months in offering B an assessment and diagnosing her with ADHD and that it should not have taken Mr A having to make a formal complaint to obtain this diagnosis, and the support, that his daughter needed. This amounted to a significant injustice to Band her family due to the distress, but also the lack of support and treatment, that the rejection of the second referral caused. As a result, the Ombudsman upheld Mr A’s complaint.

The Ombudsman recommended that the Health Board apologise to Mr A within 1 month of the final report. In light of the fact that there was a new process in place for processing and triaging neurodevelopmental referrals within the Health Board, the Ombudsman did not consider it relevant to make any specific recommendations in respect of neurodevelopmental referrals to ISCAN. However, she recommended that, within 6 months of the final report, the Health Board should review the effectiveness of the neurodevelopmental referral pathway that was implemented in April 2021 in meeting the needs of children and young people.