Report Date


Case Against

Swansea Bay University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Mrs B complained about the mental health care and treatment provided by Swansea Bay University Health Board to her husband, Mr C, between October 2020 and October 2021. Specifically, the investigation considered complaints that the Health Board failed to:

a) Provide appropriate psychiatric review, particularly in response to GP referrals in the summer of 2021.

b) Provide appropriate review and support in relation to Mr C’s medication regime.

c) Make adequate arrangements to support Mr C’s mental health needs.

d) Respond adequately to the concerns raised by Mrs B.

The investigation found that the Health Board failed to provide an appropriate psychiatric review in June and July 2021 in response to concerns raised by 2 GPs and Mrs B. It was likely that the failure to provide the expected level of care was a significant contributory factor in the deterioration of Mr C’s mental health to the point where he took 2 intentional medication overdoses in late July 2021. Accordingly, the Ombudsman upheld this complaint.

The investigation found that while Mr C had received appropriate medication reviews and support, he had not been informed of the outcome of relevant discussions as promised. To that limited extent, the second complaint was upheld.

The investigation found that, following the decision to transfer Mr C to a different community mental health team, there was a failure to provide appropriate regular support. Accordingly, the Ombudsman upheld the third complaint.

The Ombudsman also upheld the fourth complaint on the grounds that the Health Board’s response to Mrs B’s complaint was not adequate.

The Ombudsman recommended that the Health Board should apologise for the failings identified and make a financial redress payment of £1,250 for the injustices caused to Mrs B and Mr C. The Ombudsman also recommended that the Health Board should discuss this report at an appropriate clinical governance meeting and update its policies to ensure that transfers of care between its community mental health teams are completed swiftly.