Report Date


Case Against

Betsi Cadwaladr University Health Board


Clinical treatment outside hospital

Case Reference Number



Upheld in whole or in part

Mr D complained that Betsi Cadwaladr University Health Board’s (“the Health Board’s”) mental health services failed to adequately and appropriately treat his condition of Emotionally Unstable Personality Disorder – EUPD (with related anxiety and depression). Mr D complained that mental health clinicians:

1. Failed to facilitate and/or refer him for appropriate psychological therapies in accordance with established clinical guidance.

2. Declined to provide him with appropriate help and support for his addictive/impulsive behaviours (such as gambling).

3. Failed to regularly review and assess his medication needs and failed to provide him with a Care Co-ordinator.

4. Failed to fulfil undertakings given to him in relation to care services at a meeting in November 2019.

The Ombudsman upheld complaints1 and 3. With regard to complaint 1, he found that, contrary to NICE guidance, Mr D’s care was managed by the Primary Care Mental Health Service (PCMHS) and he was not referred to secondary care(the community mental health team) as his borderline personality disorder required. Consequently, he did not receive appropriate psychological therapy that might have addressed his impulsive behaviour. With regard to complaint 3, the Ombudsman found that Mr D’s medication was managed appropriately but he was not provided with a Care Co-ordinator as warranted by his condition. This disadvantaged Mr D as the PCMHS could not access, on his behalf, the appropriate psychotherapy that his condition required.

The Ombudsman did not uphold complaint 2 as, in the absence of an NHS-wide gambling-addiction treatment framework, Mr D’s involvement with Gamblers Anonymous was considered (under the terms of the NICE Guidance) an ‘appropriate service’.

The Ombudsman found no evidence that undertakings given to Mr D in relation to care services at a meeting in November 2019 were not fulfilled.

The Ombudsman recommended that the Health Board provides Mr D with an apology for the identified failings and makes a payment of£250 to him in recognition of the time and trouble to which he was put in complaining about these matters. He also recommended that the Health Board:

· Evidences that the report has been shared and discussed with the clinicians referred to within it and that they undertake revision of and reflection on the NICE Guidance.

· Reviews the available treatments and treatment pathways for EUPD and provides the Ombudsman with a summary of its findings.

· Reminds clinicians of their obligation to record clinical and care-management decisions in detail.

· Offers Mr D a fresh assessment of his condition and, depending on the outcome, reviews his plan of care.

The Health Board accepted the report’s findings and recommendations.