Report Date


Case Against

Cwm Taf Morgannwg University Health Board


Clinical treatment outside hospital

Case Reference Number



Upheld in whole or in part

Mr M complained about the care provided by the Health Board to his son, Mr A. Specifically, Mr M complained that the Health Board’s Crisis Resolution and Home Treatment Team inappropriately discharged Mr A, having failed to carry out an adequate assessment of his mental health needs, on 27 December 2018, and the Health Board also failed to undertake adequate assessments of Mr A between 25 and 30 August, and 16 and 18 September 2019. Mr M also complained that the Health Board failed to provide Mr A with appropriate mental health services between 1 October 2019 and 29 May 2020, and that it failed to respond to his complaint in an adequate and timely manner.

The investigation found there was no indication that the assessments of Mr A on 27 December were inadequate. The first complaint was not upheld. The investigation also found that Mr A received appropriate assessments during his admissions of 25 to 30 August and 16 to 18 September, and therefore the second complaint was again not upheld.

The Health Board accepted that it had failed to process a referral to its Autistic Spectrum Disorder service on behalf of Mr A, and that he had been discharged without appropriate plans in place from the Crisis Resolution and Home Treatment Team, in September 2019. The Health Board also acknowledged that it had accidentally discharged Mr A from its Primary Mental Health Support Service in November 2019, and he was not advised of his discharge. This caused Mr A injustice, because it apparently closed off suitable routes of support for him. This complaint was upheld.

The investigation found that the Health Board failed to update Mr M regarding the progress of his complaint, and no progress appeared to have been made, until Mr M wrote to the Health Board 5 months after his complaint was accepted for investigation. This put Mr M to avoidable time and trouble pursuing a response to his complaint. Further, Mr M said one of the outcomes he sought to his complaint was a review of Mr A’s mental health needs. This was not undertaken until some 4 months after it could have been identified as an outcome.

The Health Board agreed to apologise to Mr M and to pay to him the sum of £250 in relation to the time and trouble associated with pursuing his complaint response. It also agreed to remind all complaint handling staff of the importance of clarifying the details of complaints at the earliest opportunity and keeping complainants updated.