Mental health: No Cwm Taf change since daughter's death, says mum

A mother says a report critical of a mental health service shows nothing has changed since her daughter's death.

Sue Miller felt Lowri, 32, should not have been discharged from the Royal Glamorgan Hospital in 2020, and says the report shows other families have suffered similar devastation.

A Healthcare Inspectorate Wales (HIW) review into discharges found "clear risks" to patient safety.

Cwm Taf Morgannwg health board said it was committed to putting issues right.

The review of adult mental health units in Rhondda Cynon Taf, Merthyr Tydfil and Bridgend, carried out in 2022 and 2023, was prompted by concerns raised by patients' relatives and carers, staff whistleblowers and findings of previous inspections.

HIW found patient safety concerns of "such significance" that it ordered the health board to submit an immediate improvement plan.

The watchdog questioned whether the health board had "robust governance processes" in place for the safe discharge of patients from hospital.

The report refers to two patients who died after being discharged from the Royal Glamorgan Hospital in Llantrisant and says significant risks, including self-harm and suicide, were highlighted prior to discharge but "no robust management plan" was put in place for either individual to maintain their safety in the community.

It also raised broader concerns about "dysfunctional" communication and information-sharing about patient records, a lack of family and carer involvement in discharge planning, and demand for beds leading to some discharges being brought forward, exacerbating risk to patient safety.

Sue Miller gave evidence to the review and said that when she read the report she was struck by the account of the Royal Glamorgan patients.

"I thought I was reading about my daughter," she said.

"Unfortunately two more families are going through the devastation we have gone through."

Lowri had a happy childhood but struggled with her mental health in her teenage years, her mother said.

She died in February 2020, a day after being discharged from the mental health unit at the Royal Glamorgan Hospital.

Lowri had a "sudden cardiac event" at a friend's house after taking a mixture of drugs.

She had self-harmed while she was an inpatient and Sue said her discharge had been "totally against our wishes".

A review conducted by the health board after Lowri's death concluded that the "tragic incident" was "neither predictable, nor preventable", but also raised questions about her care at the hospital.

It found there was a "lack of exploration" of the concerns raised by Lowri's social worker and mother about her state of mind and "suicidal thoughts" and that there were "clear expressions of hopelessness and distress" from Lowri.

Sue said she was "so sad" that following that review of Lowri's death "it doesn't seem anything has changed".

"The same issues - communication, lack of input from families and carers," she said.

"Something seriously needs to be done."

"Obviously my daughter's death made no difference at all," she added.

"I was hoping her death could have implemented change but obviously people's needs are still not being addressed."

Alun Jones, chief executive of HIW, said: "It is disappointing to have identified such clear risks to patient safety during this review.

"HIW will closely monitor the progress made against the 40 recommendations set out within the review's report."

Greg Dix, executive director of Nursing and Midwifery at Cwm Taf Morgannwg University Health Board said: "We fully acknowledge the findings of the HIW report and have worked with urgency to achieve the immediate actions set out by the review team following their visit last year.

"As a health board, we had identified internally many of the issues set out in the HIW report and are progressing our Mental Health Inpatients Improvement Programme, which includes measures to ensure the safe discharge of patients as well as better systems for managing and sharing clinical records.

"We are implementing a robust plan for staff training, which focuses on risk assessment and the safety of our staff and patients.

"Along with our dedicated team of mental health colleagues, we are committed to putting right all of the issues identified in this report and providing the very best care, experience and outcomes for our patients and their loved ones."

In the Senedd last week Plaid Cymru MS for South Wales Central, Heledd Fychan, asked for assurance that the Welsh government is "monitoring the situation and supporting the health board" to make the necessary improvements.

In response, minister Lesley Griffiths said officials are monitoring progress through "targeted intervention arrangements" with the health board.