Source · PSOW (Public Services Ombudsman for Wales)

Betsi Cadwaladr University Health Board

PSOW (Public Services Ombudsman for Wales) Partly Upheld Reference PSOW-202408740 Sector Health Category Adult Mental Health Decided 18 March 2026

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Full decision

Ms E complained about the standard of care provided to her adult daughter, Ms F, by one of the Health Board’s community mental health teams (“the CMHT”).

The Ombudsman’s investigation considered whether: a) Whether the psychology approach in undertaking exposure therapy was appropriate.

b) Whether the decision not to arrange an assessment for ADHD/ASD was appropriate.

c) Whether the decision to discharge Ms F from the CMHT was appropriate.

The Ombudsman found that the psychological therapy approach was in line with appropriate clinical practice and guidelines, based on Ms F’s presenting symptoms. This aspect of the complaint was not upheld.

However, the Ombudsman was satisfied that there was evidence that a referral for an ASD assessment should have been made by the CMHT, and this aspect of the complaint was upheld. In relation to the decision to discharge Ms F from the CMHT services, this was not a clinically unreasonable decision. However, there were some shortcomings in how it was reached. Specifically, there was a lack of consultation with Ms F and an absence of clear information about the referral pathway for ASD assessment. This aspect of the complaint was partly upheld to that extent.

The Health Board agreed to the Ombudsman’s recommendations which included an apology to Ms F for failing to refer her for an ASD assessment and to make that referral if Ms F still wished this. It also agreed to review its ASD/ADHD policies and referral pathways to ensure that they identify, and have clear pathways to refer, cases for ADHD/ASD assessment in line with NICE guidance (CG142) and the Quality Standard.

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