Mr C complained about the standard of mental health care provided to his nephew, Mr B, by Betsi Cadwaladr University Health Board (“the Health Board”). Mr B, a 50 year old man, had schizophrenia and lived with and cared for his elderly mother, who had dementia. She entered full time care, leaving Mr B living alone in the family home. Sadly Mr B died after intentionally entering the sea, fully clothed.
The Ombudsman’s investigation considered whether: a) The risk assessment carried out was in line with accepted clinical practice. Specifically, did it appropriately reflect the risk of harm to Mr B, including his previous history of harm.
b) The support provided to Mr B by the Health Board in the community was of an appropriate standard.
The Ombudsman found that: • There were shortcomings in the risk assessment and care planning process. The fact that Mr B had previously, albeit some decades before, self-harmed and attempted suicide was not reflected in his current risk assessment. It should have been. The Health Board’s review had also not identified this issue. There was also no evidence in the care plan that staff had discussed with Mr B the possibility of sharing his “risk behaviours”, outlined in his care plan, with his family so they may be able to identify these and offer additional support.
• The level of support offered to Mr B was reasonable.
The Health Board agreed to the Ombudsman’s recommendations including that it should: • Apologise to Mr B’s family for the identified shortcomings.
• Update the Ombudsman, and Mr B’s family, about the action it took (to implement its own recommendations) following its review of the complaint.
• Provide audit evidence to the Ombudsman that the standard of care plans and risk assessments was appropriately monitored.
• Assess whether any additional action was needed in relation to risk assessment, communication and information sharing with family, and care planning.