Report Date


Case Against

Betsi Cadwaladr University Health Board



Case Reference Number



Early resolution

Mr X complained about the lack of any contact or support from Conwy CMHT between June 2022 and February 2023 despite having a care and treatment plan in place.
The Health Board accepted that, during this period there was no contact from the CMHT, and there were no care records relating to Mr X between September 2021 and February 2023.
In its complaint response, the Health Board apologised to Mr X for the failing and outlined the action that it had taken to prevent a recurrence. This included an audit of all open patient notes to check that there were no other documentation gaps. It further explained to the Ombudsman that it had introduced safeguards in its system, including an electronic spreadsheet to document the last contact with patients, so that any overdue contact with patients would be highlighted.

The Ombudsman was concerned that the CMHT’s processes may not be robust to ensure that patients were not overlooked. The Health Board therefore agreed (within 2 months) to:
• Review the CMHT’s system for identifying when a care and treatment plan review is overdue.
• Audit and review the improvements it had made to the CMHT processes following the complaint to ensure that its current system was robust.
The Health Board also agreed to provide an additional complaint response to Mr X covering the issue of qualifying liability in line with the regulations.