Source · PSOW (Public Services Ombudsman for Wales)

Aneurin Bevan University Health Board

PSOW (Public Services Ombudsman for Wales) Not Upheld Reference PSOW-202409492 Sector Health Category Clinical treatment in hospital Decided 12 March 2026

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Mr J complained that a joint risk assessment undertaken by the Council and the Health Board and provided to a Supported Housing Provider (SHP) was missing key information about his son’s needs. This led to him being placed in what Mr J believed to be an unsuitable placement.

Mr J also complained that the Council was not willing to carry out its own investigation into his concerns about the risk assessment when a proposed joint investigation with the Health Board did not progress.

The investigation against the Council identified failings around documentation and how aspects of the care co-ordinator role had been carried out. However, the Ombudsman concluded that, prior to the placement, the SHP was provided with sufficient key information about the needs of Mr J’s son by the Health Board who was jointly involved in commissioning the placement. In relation to the Council and the Health Board, this part of Mr J’s complaint was not upheld.

The Ombudsman found that an opportunity for the Council to identify and learn lessons from Mr J’s complaint was missed by its decision not to carry out its own investigation. The injustice for Mr J was that he had to complain further in order to obtain answers. This part of Mr J’s complaint was upheld.

The recommendations to the Council included apologising to Mr J and carrying out an audit across the Community Mental Health Teams in order to satisfy itself that the requirements of the care co-ordinator role, as well as wider processes and systems, are being met. As part of the audit process the Council was asked to engage with the Health Board as appropriate.

The Health Board was invited to engage with the Council around the audit recommendation set out above, as this would also provide an opportunity to ensure that any wider points of learning around systems and processes in relation to jointly commissioned care are maximised.

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