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Clinical treatment outside hospital : Cwm Taf Morgannwg University Health Board

Report date

21/06/2021

Subject

Clinical treatment outside hospital

Outcome

Upheld in whole or in part

Case ref number

201903330

Report type

Non-public interest report issued: complaint upheld

Relevant body

Cwm Taf Morgannwg University Health Board

Ms C complained about her daughter, H’s, management and care by Cwm Taf Morgannwg University Health Board’s “(the First Health Board’s”) Child and Adolescent Mental Health Services (“CAMHS”), including what Ms C felt was an unreasonable delay in diagnosing her daughter’s Borderline Personality Disorder (“BPD”). Ms C also complained about a lack of support provided to her prior to 2018, and that CAMHS failed to respond to respond to a letter from her. Ms C further complained about H’s management and care by Cardiff and Vale University Health Board (“the Second Health Board”) which took over management of CAMHS on
1 April 2019. She said that the Second Health Board did not recognise that BPD could exist in children and was failing to help children in severe distress. Ms C also complained that there had been a lack of support provided to her.

The Ombudsman found that the diagnosis of BPD is often not formally diagnosed in a person under 18. He found no undue delay in diagnosing BPD in H, and found that her management and care by the First Health Board met an appropriate standard. However, he found failings in care planning which adversely affected Ms C and her daughter, and to that extent he upheld the complaint. He found that whilst individual members of CAMHS staff made considerable efforts to support Ms C, the First Health Board failed to provide a Care Co-ordinator as a point of contact who

could have provided her with an overview of H’s care. He also found that the First Health Board failed to inform the Second Health Board of the support Ms Chad been receiving from a practitioner who was not moving to the Second Health Board. The Ombudsman upheld the complaint about the support provided to Ms C, and he also found that the First Health Board should have responded to the letter she sent.

The Ombudsman did not uphold Ms C’s complaint about the Second Health Board’s care and management of H from April 2019. He found that after April 2019, CAMHS did recognise BPD in H and it provided appropriate treatment. The Ombudsman did not uphold the complaint about the support provided to Ms C by the Second Health Board.

The Ombudsman recommended that the First Health Board apologise to Ms C. He also recommended that the First Health Board CAMHS review its care planning processes to ensure compliance with the Mental Health (Wales) Measure 2010 and Code of Practice. The First Health Board also offered to pay £250 to Ms C to reflect its poor complaint handling and the additional distress caused.

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