From Complaints to Coroners' Warnings — Still No Action. It’s Time for Change
I've had some on social media tell me, ‘Just do a complaint — there’s no need for all this publicity or a petition.’ But this proves exactly why I had to speak out. There have been countless complaints over the years — including Iestyn's detailed case months ago — and still nothing has changed. The same harmful practices continue unchecked. There have been many coroners’ reports and Prevention of Future Deaths notices — and still no action. Speaking out publicly isn’t attention-seeking — it’s survival and a call for change.
Previous Complaint – Commitments Made by the Health Board
On 11th December, a formal complaint was made by another patient, Iestyn. In response, the Health Board claimed they would take the following actions:
• Reduce the use of excessive force and ensure staff are properly trained in de-escalation skills and techniques
• Provide specialist training to help staff understand and support patients through emotional distress
• Educate staff on confidentiality and the importance of respecting patient privacy
• Maintain a therapeutic and safe environment for patients, with staff trained to understand the impact of mental illness
• Promote a zero-tolerance approach to harmful or disrespectful attitudes toward service users
These were the Health Board’s own commitments — made in writing — in response to Iestyn’s complaint.
You can read the full Health Board reply here:
What Happened to Me – Months Later
Despite these commitments, the same failings happened in my care just months later, proving clearly that no learning took place and no meaningful action was implemented.
• I experienced unnecessary excessive force used against me in distress - which was often escalated by staff. Staff didn’t follow proper procedure before and whilst handling me. Effective de-escalation techniques were not utilised.
• I was accused of lying while in clear suicidal distress — called “attention-seeking” and “that I was fine... no signs of agitation or anxiety” One staff member even asked me why I was “smiling” when I wasn’t.
• I was actively suicidal, but my risk was downplayed and ignored.
• Staff frequently breached confidentiality — gossiping about patients, accusing one girl who’d just been on train tracks of “just coming back to see me,” and spreading lies about my mother.
• I was lied to about therapies being chased or was even told I'd never been promised any specific therapies despite my notes stating different.
• My distress was made worse by staff behaviours — hostile attitudes, dismissal, and cruelty.
• The ward was not a safe or therapeutic environment. Staff showed little to no understanding of mental illness.
• My attempts to advocate for myself were treated as difficult or manipulative — not as signs that I was unwell and in need of help.
The Complaints Process Is Still Broken
The Health Board’s response to Iestyn’s complaint sounded like change. But the reality shows otherwise. In practice:
• Commitments were vague, non-binding, and not acted upon
• The same failures continued in other patients’ care — including my own
• No cultural or structural change occurred
• Lessons were not learned
• Accountability is still absent
This is not just about Iestyn or myself. There have been many, many complaints over the years, from many people.
There have been multiple coroners’ reports and Prevention of Future Deaths reports.
Still, these failures persist.
Internal complaints are not enough. They are slow, defensive, and dismissive. That’s why this petition matters. That’s why we are speaking out.
Iestyn’s Story: “I Wasn’t Being Difficult. I Was Unwell.”
Wales, July 2025
A 21-year-old man named Iestyn, from South Wales, has come forward with a powerful account of how he was repeatedly failed by mental health services — left without proper diagnosis or treatment for nearly a decade.
He first started struggling at age 13. Referred to CAMHS, he was told he had “no mental disorder” — just “behavioural problems.” Neither he nor his mother, who tried relentlessly to advocate for him, were believed. His mother, whom he describes as his biggest supporter, continued to fight on his behalf, but says she too was repeatedly dismissed by professionals.
The system failed him and his family. “They made us feel like we were exaggerating, like there was nothing wrong. But there was.”
In the last four years, he was sectioned under the Mental Health Act eight times, repeatedly admitted to Ward F at Neath Port Talbot Hospital — which he describes as unsafe and traumatic. “There was no care or compassion. Just control and judgement", he says.
He recounts being labelled “attention-seeking” and "just behavioural" whilst in crisis by Dr. Robertson. His concerns he'd end his life early were dismissed - she openly said "just do it then" whilst he was suicidal and in distress. He was forcibly restrained, and even grabbed by the throat by a staff member. One one occasion, after trying to leave the ward, he was forcibly restrained, which left him with bruises.
He also recalls breaches of confidentiality, where staff openly discussed private information about other patients in shared spaces.
Only after a life-threatening crisis did he finally receive an accurate diagnosis and appropriate medication — nearly ten years too late.
“If services had listened when I was 13, none of this would’ve happened.” "So much pain, trauma, and danger could have been avoided.”
Now in Cefn Coed hospital with a care team that finally supports him, he says:
“I’m not speaking out to shame anyone. I’m speaking out because if we don’t tell the truth, nothing will ever change. We need professionals who investigate properly, who care. Mental health wards should be places of healing — not places of fear. Crisis teams should act with urgency and compassion not make people feel like a burden.”
Accountability, Not Excuses – The Case for Body Cameras on Psychiatric Wards
As a direct result of his traumatic experiences, Iestyn made a formal call to the Welsh Government, urging them to introduce mandatory body cameras for all staff in psychiatric hospitals across Wales. His reasoning is clear - just as police are held accountable through body-worn footage when using force, so too should staff on mental health wards be monitored when physical intervention is used.
This is not about punishment — it’s about protection, transparency, and accountability.
Mental health staff are legally and ethically obligated to use the least restrictive options available. Physical restraint should be a last resort, and only applied when there is clear, immediate risk. Effective de-escalation should always come first.
But, on Ward F, this principle is repeatedly ignored.
Staff often respond with dismissiveness, provocation, and antagonising remarks in moments of acute distress, making situations worse, not better. There is no visible culture of de-escalation or compassion, and no consequences for harmful staff behaviours.
I fully support Iestyn’s call for body cameras. This measure would protect patients and staff, and expose abuse, misuse of restraint, and failures in care that currently go undocumented and unchallenged.
The Welsh Government’s Weak Response – And Their Responsibility
Iestyn raised this directly with the Welsh Government — the very body responsible for overseeing and regulating health boards in Wales.
Their response? They passed the responsibility back to the Health Board.
You can read the reply here:
This is not good enough.
The Welsh Government claims it is “committed to improving the quality and safety of care on mental health inpatient wards” — but so far, this remains a hollow statement, unsupported by real, visible action.
Why the Welsh Government Must Step In
The Health Board has already shown it cannot be trusted to police itself.
Despite:
• Years of complaints
• Repeated failings
• Prevention of Future Deaths reports
• Independent reports
• Whistleblowing from patients and families
The same dangerous practices continue.
Patients are still harmed. Staff still act recklessly with neglect. Promises are still broken.
If the Welsh Government acknowledges that safe, high-quality mental health care is a national priority, then they have a legal and moral duty to intervene when a Health Board fails to meet that standard.
This includes:
• Mandating oversight where there is clear evidence of systemic failure
• Establishing accountability for national minimum safety and training standards
• Reviewing and reforming restraint practices and oversight
• Funding and legislating for body-worn cameras on psychiatric wards
We will be pursuing this again.
Because if not now — after so many warnings, complaints, and tragedies — then when?
⚖️ The Welsh Government Has a Legal Duty to Act
They say this is a Health Board issue. But in truth, Welsh Government has legal responsibilities too.
Under:
• NHS (Wales) Act 2006
• Mental Health (Wales) Measure 2010
• Human Rights Act 1998
• Equality Act 2010
the government is obliged to ensure safe, lawful, and effective care.
They have the power to:
• Direct Health Boards to fix unsafe practices
• Intervene when there is a clear pattern of failure
• Protect patients' human rights and uphold mental health law
Saying “we’re committed to improving services” means nothing when real people are still being harmed.
Why This Petition Matters
Iestyn’s case was meant to be a wake-up call. It wasn’t.
So were the many complaints before his.
So were the Coroners’ Reports.
So were the Prevention of Future Deaths reports.
But nothing has changed.
That’s why we’re speaking out. That’s why we need accountability. That’s why this petition exists.
Please keep sharing, speaking out, and standing with us.
Kind regards,
Jacob Robertson
Petition Organiser, Campaigning for Justice in Mental Health Care
Iestyn
Survivor of Swansea Bay Mental Health Services, Advocate for Patient Safety and Reform