Report Date


Case Against

Cwm Taf Morgannwg University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Mr A has complained about the care and treatment his wife, Mrs A, received from the Health Board following her admission to hospital on 19 November 2021. We investigated whether Mrs A was treated appropriately and given sufficient support in hospital; specifically, if her further attempted overdose could have been avoided and whether the decision to discharge her was appropriate. We also looked at whether, after her discharge, Mrs A was given sufficient support by the Community Mental Health Team (“CMHT”) and Crisis Resolution Home Treatment Team (“CRHTT”) on 22/23 November, and whether the complaint response provided by the Health Board was in line with the relevant complaint handling guidance.

The investigation found that the overall approach to Mrs A’s clinical management during her initial admission, and the decision to discharge on 21 November, was largely appropriate. However, there were elements of concern regarding Mrs A not being offered an additional opportunity to engage with the Mental Health Liaison Team on 20 November and being advised against attending a mental health specialist ward due to lack of beds, which was sufficient to partly uphold this element of the complaint. The investigation found that the support offered by the CMHT and CRHTT was generally appropriate and consistent with mental health services generally. This element of the complaint was therefore not upheld. Finally, it found that while the Health Board’s own complaint investigation technically did not fall outside the time parameters of complaint handling guidance, it was extended and opportunities were missed to have made responses clearer and more thorough. This element of the complaint was therefore partly upheld.

We recommended that within 1 month of the final report, the Health Board should apologise to Mr and Mrs A for the issues identified, bring our report to the attention of all staff working within mental health departments (hospital and community based) and remind them that patients should not be discouraged to contact relevant support services due to lack of bed availability. We also recommended that the Health Board should remind all complaint handling staff of the importance of identifying evidence other than medical records (such as telephone recordings) when relevant, as soon as possible, and ensuring they are referred to and retained throughout the complaints process.