Report Date


Case Against

Swansea Bay University Health Board


Clinical treatment outside hospital

Case Reference Number



Upheld in whole or in part

Ms A complained about the care and treatment received by her late brother from the Health Board’s Community Mental Health Team. In particular, she complained that, between October 2018 and May 2019, the Health Board failed to provide an adequate level of monitoring of her brother’s mental health, and that the deterioration in his mental health was not appropriately identified or documented. She also complained that the Health Board’s communication with the family was poor and their concerns were not adequately recorded or acted upon.

The investigation found that the Health Board’s records were comprehensive and that the level of mental health monitoring provided was frequent and in line with clinical guidelines. This aspect of Ms A’s complaint was not upheld. The investigation also found that the Health Board’s Community Psychiatric Nurse discussed care arrangements with the family and that these conversations were well documented. Failings were found, however, in the timeliness of the Health Board’s response to Ms A’s complaint, with its formal response taking 5 months to issue. This delay caused the family further distress during what was already a very difficult time. This part of Ms A’s complaint was therefore upheld to this limited extent.

The Ombudsman recommended that, within 1 month of his report, the Health Board should apologise to Ms A for the failings identified and make a redress payment of £250 in recognition of the time and trouble of bringing her complaint to his office.