The Ombudsman considered complaints made by Ms A about her treatment by the Health Board, specifically that the Community Mental Health Team (“CMHT”) Team Lead who spoke to her on 29 January 2021 did not support her sufficiently and breached her duty of care to Ms A, and that the record of the call made by the CMHT Team Lead was inaccurate. Ms A also complained that her later discharge from the CMHT, including her transfer of care to a new locality, was not managed appropriately, and that the Health Board’s response to her complaint was insufficient and not in line with the Putting Things Right (“PTR”) process.
Based on the evidence provided, which included a covert recording made by Ms A of the January telephone conversation, the Ombudsman found that it was more likely than not that several key elements of the Health Board’s summary of the call within the clinical records were inaccurate. As a result, she found that, whilst the support provided by the CMHT during the call was not inappropriate, given that Ms A indicated a possible suicidal intention, references to support agencies should have been made, and, as they were not, this was an injustice to Ms A. She found that although the complaint response was largely in line with PTR, it did not appear to have sufficiently considered Ms A’s recording of a telephone call when creating the response, or when subsequently providing comments to the Ombudsman. These 3 complaints were therefore upheld. The Ombudsman found that Ms A’s discharge and transfer were generally managed appropriately so this complaint was not upheld.
The Ombudsman recommended that the Health Board should apologise to Ms A for the issues identified and offer her a payment of £750 in recognition of the failure to refer to support agencies within the telephone conversation and poor complaint handling. She also recommended that the Health Board should remind all staff within the CMHT of the importance of completing records as soon as possible after the relevant conversation/consultation and should consider its procedure for recording conversations with patients and whether this needs to be reviewed.