Report Date


Case Against

Hywel Dda University Health Board


Patient list issues

Case Reference Number



Upheld in whole or in part

Mrs M complained about the care and treatment that her daughter, Ms D, received from the Health Board’s Mental Health Services following the onset of 2 acute psychotic crises. Mrs M complained that, on 20 December 2019:

1.The Health Board failed to arrange for a Section 12 approved doctor to visit Ms D at home to conduct a Mental Health Act (“MHA”) Assessment.

2.An Approved Mental Health Professional improperly declined to authorise an emergency application for Ms D’s admission under Section 4 of the MHA.

3.Mrs M was obliged to take Ms D (in a state of severe distress) by car to hospital.

Mrs M also complained that, on 23 February 2020:

4.Mr and Mrs M took Ms D to hospital but, as there were no available beds, the family was obliged to spend the night in the Emergency Department. There were no checks made by clinicians on Ms D during the night.

5.Ms D’s dignity was compromised when she was obliged to undergo a mental health assessment in her pyjamas.

6.Mrs M complained that, following discharge, there were protracted delays in Ms D being placed on a waiting list for psychological therapy and in the Health Board responding to her complaints.

The Ombudsman upheld complaint 1. Whilst she acknowledged that the shortage of Section 12 doctors reflected an NHS-wide shortage that was not limited to the Health Board, she found that attempts to secure a Section 12 doctor for Ms D lacked any systematic escalation process. The Ombudsman did not uphold complaint 2 on the grounds that clinicians reasonably attempted to prioritise securing a Section 12 doctor home visit (as the preferred procedural option carrying the least risk). The Ombudsman upheld complaint 3 to the extent that the failure to secure a Section 12 doctor placed the family in the position of having to accept a degree of risk in order to obtain the care that Ms D needed. The Ombudsman partially upheld complaint 4. She found that delay in the provision of an available bed for Ms D was, again, partly a reflection of underlying resource shortages within and across NHS Mental Health Services. However, she also found that there were omissions of important information which, had it been provided to the family, might have made it less likely that they would have pursued and escalated their complaint. The Ombudsman partially upheld complaint 5. Whilst she did not consider that the incident amounted to a serious breach of Ms D’s right to dignity and privacy she nevertheless invited the Health Board to reflect on this matter and proposed that an apology be provided. With regard to complaint 6, the Ombudsman found that Ms D’s wait for psychological therapy was, under the circumstances, reasonable, but that there were a number of complaint-handling shortcomings. She therefore partially upheld this complaint.

The Ombudsman recommended that the Health Board:

•Provides Mrs M with a fulsome apology for the failings identified in the report and makes a payment to her of £500. She also recommended that the Health Board:

•Confirms that the report has been discussed within its Mental Health Directorate and relevant CMHT, CRHT and AMHP teams.

•Provides evidence of the initiatives and improvements to services (as referred to in its correspondence) in respect of implementing strategies to address shortages of trained psychiatrists, Section 12 approved psychotherapists and other mental health clinicians.

•Provides the Ombudsman with evidence of the development of an escalation policy in relation to managing contacts with Section 12 approved doctors.

The Health Board agreed to implement these recommendations.