Report Date

16/11/2023

Case Against

Betsi Cadwaladr University Health Board

Subject

Services for vulnerable adults (eg with learning difficulties. or with mental health issues)

Case Reference Number

202204812

Outcome

Upheld in whole or in part

Ms C complained about the mental health care that she received from Betsi Cadwaladr University Health Board between November 2021 and January 2022. Specifically, Ms C complained that the Health Board:
a) inappropriately discharged her from its mental health units on at least 2 occasions without putting sufficient community-based support in place
b) inappropriately sectioned her under the Mental Health Act 1983
c) failed to appropriately involve her in decisions about her care prior to her discharge on 14 January 2022.
The investigation found that the mental health care Ms C received from the Health Board between November 2021 and January 2022 was appropriate. There was, however, a failing in the Health Board’s record keeping which meant that the Ombudsman was not able to fully investigate Ms C’s complaint. The Ombudsman upheld complaint a) to that limited extent. The other complaints were not upheld.
The Health Board agreed to the Ombudsman’s recommendations to apologise to Ms C for the record keeping failure identified and the resulting inability of the Ombudsman to determine part of her complaint. It also agreed to take appropriate steps to ensure that the failings would not be repeated, having regard to the Ombudsman’s thematic report “Justice Mislaid: Lost records and lost opportunities” and guidance on good administration and good records management.