Source · PSOW (Public Services Ombudsman for Wales)

Hywel Dda University Health Board

PSOW (Public Services Ombudsman for Wales) Upheld Reference PSOW-202000537 Sector Health Category Adult Mental Health Decided 26 May 2021

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Ms D complained that the Hywel Dda University Health Board (“the Health Board”) failed to provide her partner, Mr B, with appropriate care and treatment. In particular, Ms D complained that the Health Board failed to provide Mr B with appropriate mental health support and treatment and that Mr B experienced delays and difficulties in obtaining a dual diagnosis for his mental ill-health. Finally, Ms D complained that the Health Board failed to communicate appropriately with both Ms D and Mr B, which caused added distress and worry.

The Ombudsman’s investigation found that the Health Board carried out appropriate assessments for Mr B and offered him appropriate treatment options. The investigation found that the Health Board’s management plan was appropriate. Accordingly, the Ombudsman did not uphold this element of Ms D’s complaint. The investigation also found that the Health Board’s communication with Mr B and Ms D was frequent and appropriate. The investigation found that while the Health Board sent a letter which incorrectly stated that no diagnosis had been made following Mr B’s psychiatric assessment, this did not impact on Mr B’s clinical care or care plan. Accordingly, the Ombudsman did not uphold this element of Ms D’s complaint.

The Ombudsman’s investigation found that dual diagnosis did not extend to Mr B’s particular comorbidities. However, there was a delay in Mr B receiving an appropriate diagnosis for his mental health problems from the Health Board. Mr B experienced a delay in receiving a full psychiatric assessment which was a service failure. This led to an injustice to Mr B and Ms D because the delay in obtaining a diagnosis caused uncertainty and added distress for them. However, the investigation found that the delay in diagnosis did not impact the clinical management of Mr B and therefore the injustice was limited.

Accordingly, the Ombudsman partly upheld this part of Ms D’s complaint. He recommended that the Health Board should apologise to Mr B and Ms D for the delay in Mr B’s psychiatric assessment and that the Health Board should carry out a review to ensure that patients who require a Consultant Psychiatric assessment are assessed in a timely manner.

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