Report Date


Case Against

Aneurin Bevan University Health Board


Clinical treatment in hospital

Case Reference Number



Not Upheld

Ms A complained on behalf of her daughter, B, about the appropriateness of mental health assessments carried out by the Children and Adolescent Community Mental Health Service (“CAMHS”) during her admission to the Royal Gwent Hospital (“the Hospital”) in May 2020 after she swallowed some button batteries. B reacted badly to being told that she was going to be discharged back to her residential placement, and in separate incidents, she ran out of the Hospital in front of traffic and then jumped off a 20ft wall and was injured. Ms A said that more should have been done to keep B safe during her admission and she questioned the appropriateness of ongoing plans to return B to the placement in view of the escalation in her behaviour.

The Ombudsman found that the assessments of B were conducted to an appropriate standard. The decisions taken were evidence-based on the information available at the time and fell within the range of acceptable clinical practice in the given circumstances. Appropriate mitigation in view of B’s risk-taking behaviour was put in place in the Hospital and was also planned for her return to the placement. Sadly, B’s extreme reaction to the decision that she should return to the residential placement could not have been anticipated by the Medical Team overseeing her mental health care while she was in the Hospital. Accordingly, the plan for B changed in view of the escalation in her behaviours and an alternative plan for inpatient care was implemented. In the absence of any evidence of significant service failure, the Ombudsman did not uphold the complaint.