Source · PSOW (Public Services Ombudsman for Wales)

Aneurin Bevan University Health Board

PSOW (Public Services Ombudsman for Wales) Upheld Reference PSOW-202500889 Sector Health Category Adult Mental Health Decided 29 January 2026

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Original decision on the PSOW (Public Services Ombudsman for Wales) website ↗

Full decision

Miss C complained about the care and treatment her father, Mr A, received from Aneurin Bevan University Health Board. Specifically, the investigation considered whether Mr A’s discharge from Yysbyty Ystrad Fawr on 3 January 2024 was appropriate and whether referral to mental health or psychiatric services should have taken place sooner.

The Ombudsman found that Mr A’s discharge from the hospital was not reasonable or appropriate and was instead premature and inadequately planned. Furthermore, the investigation found that mental health/psychiatric input should have been requested before discharge. This was an injustice to Mr A and his family. The Ombudsman upheld both complaint points.

The Health Board accepted the Ombudsman’s recommendations. This included an apology and an offer of financial redress for £1000 to Miss C and to share the report with relevant clinicians who provided care and with the Health Board’s Quality and Safety Committee. The Health Board agreed to provide evidence that training on mental capacity assessment and deprivation of liberty safeguards had been implemented. It also agreed to implement training and a number of service improvements around discharge planning processes aimed at addressing the causes of the failings in this case. Finally, it agreed to carry out an audit of capacity and depravation of liberty safeguarding assessments completed within the previous year and to address any failings identified as a result.

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