Report Date


Case Against

Swansea Bay University Health Board


Clinical treatment outside hospital

Case Reference Number



Upheld in whole or in part

Ms B complained about the care and treatment she received when she contacted Swansea Bay University Health Board’s Community Mental Health Team (CMHT) seeking support and treatment for an ongoing mental health crisis. Ms B complained that the CMHT’s Consultant Psychiatrist:
1. Declined to prescribe medication which she had previously found effective for her condition
2. Abruptly discontinued all her medication without informing her that he had done so.
3. Declined to agree to admit her to hospital or to conduct an emergency assessment despite her history of mental health problems.
4. Discharged her from the CMHT without notifying her that he had done so.
The Ombudsman did not uphold complaint 1 as the medication in question was potentially dangerous and could not, in any event, be prescribed over the telephone. The Ombudsman upheld complaint 2. He determined that the decision to discontinue Ms B’s medication without discussion, warning or directly informing her, was a service failure which ran contrary to established guidance in a number of respects. Similarly, the Ombudsman upheld complaint 3 as the decision not to conduct an emergency assessment also breached established guidance and failed to evaluate risk both to Ms B and to her children. With regard to complaint 4, the Ombudsman upheld this on the grounds that the decision to discharge Ms B from the CMHT during a mental health crisis without informing her also ran contrary to established guidance and practice Whilst it was acknowledged that Ms B was abrupt and aggressive in manner during the telephone conversation with the Consultant (and terminated the call prematurely), it was neither appropriate nor safe to assume that, because of this, she had opted out of the service.
The Ombudsman recommended that the Health Board provide Ms B with a fulsome written apology for the identified failings and makes a payment to her of £750 in acknowledgement of the distress these failings gave rise to. He further recommended that the Health Board:
a) Shares the report with the relevant CMHT and discusses its findings with the Consultant
b) Reviews procedures for managing patients who are aggressive or demanding to ensure that their care needs are not jeopardised
c) Confirms that Discharge Procedures within the CMHT have been reviewed and/or modified
d) Confirms that CMHT clinicians are reminded of the importance of conducting risk and emergency admission assessments
e) Considers offering Ms B the option of undergoing a fresh care and treatment review at her local CMHT.
The Health Board accepted and agreed to implement these recommendations.