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23 Mar 2023

Actions against public authorities

Public Law and Private Client

‘Significant risks’ to patient safety identified following review

Ela Lloyd-Evans from our Public Law and Private Litigation team looks into the Health Inspectorate Wales review of mental health services at Cwm Taf Morgannwg University Health Board.

On the 7th of March 2023, Health Inspectorate Wales (HIW) released a report identifying ‘significant risks’ following a review of discharge arrangements from adult inpatient mental health units within the Cwm Taf Morgannwg University Health Board (CTMUHB).

The review’s sole focus related to the adult service provision of the Health Board, which cares for people aged 18-65 living within the three boroughs of Rhondda Cynon Taf, Merthyr Tydfil and Bridgend.

HIW have made 40 recommendations within their review for much needed improvement. Some patient safety concerns were of such significance that the CTMUHB were issued with an immediate assurance letter, following which it was required to submit an immediate improvement plan to HIW.

Key findings

Communication and Information Sharing

The HIW review identified multiple patient clinical record systems in place within the health board, including paper and several electronic systems. HIW found these to be ‘collectively dysfunctional’ and presenting ‘significant risks to patient safety following discharge from hospital’.

It also noted inconsistent use of record systems, whereby each system was not accessible to all staff involved in the patients care and staff often could not access essential information in a timely manner.

The effectiveness of communication and information sharing between inpatient and community staff teams was also identified as an issue. This resulted in occasions where patients had been discharged with limited or no communication between teams.

Patient Record Concerns

Although the review highlighted some evidence that good care and treatment was being provided to patients, the quality and availability of the information was inconsistent. This meant that it was not always clear whether all care and actions had been undertaken by staff.

Evidence suggested that risk assessments were being updated prior to discharge, however there was limited evidence of contingency/crisis plans or relapse indicators set for patients. HIW also revealed that records did not always demonstrate that patients and their family or carer had been involved in and appropriately communicated to during the discharge planning process.

In particular, significant concerns were raised for two patients discharged from the inpatient mental health unit at Royal Glamorgan Hospital. Clinical records highlighted significant patient safety concerns for both patients, which included the risk of self-harm and suicide and for one patient, the risk of harm to others. It was identified that no robust management plans were implemented for either individual as part of their discharge plan, which was pivotal to support them effectively and to ensure their safety once discharged into the community.

Capacity and Demand for services

HIW found that staff were striving to deliver mental health services in challenging circumstances, which were often exacerbated by issues with staffing capacity. This would hamper their staff’s ability to undertake the full requirements of the role, impacting negatively on morale and well-being. Whilst some progress has been made to increase staffing since HIW commenced their review, it is clear that ‘further work is required to strengthen the overall ability to meet patient demand’.

The demands on the service were also creating an issue with availability of beds in the mental health units. We are told that on occasions, planned discharges were being expedited to create space for new admissions, subsequently impacting the effectiveness and safe discharge arrangements for some patients.

Our view

The Mental Health Services in Wales have long been in a state of crisis. Harding Evans Solicitors have acted for many families who have suffered as a result of erroneous decision making and inadequate service provision.

In March 2022, Harding Evans represented the family of the Late Lowri Miller at the final inquest hearing in Pontypridd. Lowri Miller, 32 from Beddau, was admitted to the Royal Glamorgan Hospital on the 4th of February 2020 due to her history of mental ill-health and risk of overdosing. The inquest revealed that whilst Lowri was in Hospital, she had revealed to her Social Worker that she intended to take her own life and had specifically referenced the fact that she had medication stored at a friend’s house. The Social Worker expressed concern that Lowri would take an overdose if discharged. Despite this, Lowri was subsequently discharged the following day without staff alerting her family. Once discharged, Lowri’s family were contacted but despite several attempts they could not reach her. Later that day Lowri responded to their messages stating that she wanted to take her own life. The Police were informed and the family provided a list of places where Lowri might be staying. These properties were not checked until the following morning where Lowri was sadly found deceased on the 8th of February 2020.

Lowri’s mother, Sue Miller, and the rest of her family have significant concerns around the care and treatment that Lowri received during her final days, and in particular the decision to discharge her from the Royal Glamorgan Hospital without warning her immediate family, and despite the obvious risk that Lowri presented to herself.

Whilst we welcome the recommendations made by the HIW for the much needed change within CTMUHB, for families such as Lowri’s, these recommendations are too late.

During the Inquest process Ela Lloyd-Evans worked alongside Lowri’s Family and the Barrister to ensure that Lowri’s family were supported through the process, and able to get as many answers from the inquest as possible.

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