Suicide Report Critical of Cardiff Health Board

A report by the Ombudsman for Wales into the suicide of a man in 2008 has been critical of Cardiff and Vale University Health Board.

A mother complained about the standard of care afforded to her late son by Mental Health Services before he took his life in October 2008.

The Ombudsman’s investigation found that:

• The threshold for admission to a hospital bed appeared to be at a high level given there was no clear policy guidance or definition as to what constituted a “severe case” warranting admission.

• The high bar coloured the way in which the man was dealt with. This was particularly evident immediately following his return from a trip with his mother, when he had self harmed.

• There was no clear guidance in place as to what should happen when patients recently discharged from the Crisis Team’s care self presented at a hospital front desk, out of hours, requesting admission.

However, the Ombudsman did not uphold the complaint that any shortage of beds had influenced the decision not to admit the man, as he was satisfied that a bed could have been sourced elsewhere if required.

Commenting on the report Bill Walden-Jones, Chief Executive of mental health charity Hafal, said:

“The Ombudsman has to confine what he comments on to fairly technical aspects of the case and I think he’s reached the right conclusions here.

“However, there are also wider implications. I think the mother of this man has courageously posed a question for the wider public: if somebody in your family is extremely depressed and they have tried to take their own life more than once in recent days and weeks, and if they then try to get admission into hospital, what should happen?

“I think most reasonable people would say that either the person should be admitted or there should be a flexible service available which ensures that someone is available to stay alongside the person until the crisis is over.

“There is a weakness in the suicide strategy in Wales – it concentrates on early stage prevention, which is of course important, but much can also be done at a late stage when a patient is at high risk, as is evident in this case.”

To read the full report, click here.