Source · PSOW (Public Services Ombudsman for Wales)

Aneurin Bevan University Health Board

PSOW (Public Services Ombudsman for Wales) Upheld Reference PSOW-202102222 Sector Health Category Clinical treatment in hospital Decided 20 March 2023

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Full decision

Mr A complained that he had not received appropriate and sufficient support from Aneurin Bevan University Health Board’s (“the Health Board’s”) Community Mental Health Team between December 2019 and September 2020. He also complained that the Health Board had failed to take appropriate account of his complex mental health needs when he attended the Royal Glamorgan Hospital (“the Hospital”) on 1 and 15 June 2020 and failed to discharge him safely. He also complained that the Health Board had failed to respond to his complaint appropriately.

The Ombudsman considered that the Health Board had provided Mr A with appropriate and sufficient mental health support from its Community Mental Health Team between December 2019 and September 2020. This element of the complaint was not upheld. In relation to the way that the Health Board took account of Mr A’s complex Mental Health needs, the Ombudsman found it have taken appropriate action although it was invited to consider Mr A’s need for reasonable adjustments in future and to review how it identifies patients with a disability promptly when they attend the Emergency Department. The Ombudsman also found that the Health Board had not failed to discharge Mr A safely since he left the hospital before had been able to formally discharge him. These elements of the complaint were not upheld.

In relation to the way in which the Health Board responded to Mr A’s complaint, the Ombudsman found that the Health Board did not give Mr A a joint response to his concerns, took too long to provide its responses and did not fully address Mr A’s concerns about the Hospital in the response provided. The Health Board’s loss of some of Mr A’s hospital records also appears to have impacted on its ability to respond fully to Mr A’s concerns. These complaint handling failings caused Mr A distress, inconvenience and uncertainty, which amount to a significant injustice and led the Ombudsman to uphold the complaint.

The Ombudsman recommended that the Health Board apologise to Mr A, pay him redress of £750 and recommended that the Health Board takes action in an effort to try to reduce the risk of misplacing such records in future.

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