Petition Update – Ward F Complaint

After several months of delays and repeated requests for a response, I am finally able to provide a long-awaited update regarding the Health Board’s reply to my formal complaints about the care and safety I experienced during my admission to Ward F from 11th February 2025 to 23rd April 2025.

This update summarises the Health Board’s responses to the incidents I raised, highlights areas where their findings are inadequate or fail to acknowledge breaches of duty, and sets out my position and demands for accountability and systemic reform.

For supporters of this petition who may be unfamiliar with how NHS complaints work: the NHS complaints process rarely results in staff being held accountable. It is standard practice for responses to avoid acknowledging harm or breaches of duty. Instead, they often rely on excuses, misrepresentations, or irrelevant details to justify failings — for example, claiming that my questionable subjective “settled presentation” or supposable “improved sleep” mitigates failures during my care which accumulated in my suicide attempt involving Brazil nuts. Even legal advisors often warn NHS not to admit harm, as a way to limit liability.

This pattern of deflecting responsibility and providing only vague “lessons learned” without real action is exactly why this petition is needed: to push for genuine accountability, ensure that unsafe practices are corrected, and safeguard other vulnerable patients in the future.

For full transparency, the Health Board’s complete reply to my complaint can be accessed here:

Original reply
Reply with added comments

Finally, I want to thank the investigator for their work and recommendations — I understand some long nights were spent working on this until 3 a.m. — but while the report is detailed, it must now be followed by real action, not just words.

 
Section 1 – Brazil Nuts Incident

Incident Overview

While on the ward, I obtained a delivery of Brazil nuts, which I ingested in a suicide attempt, causing anaphylaxis. My life was saved only by the ambulance service. Staff were aware of my allergy and suicidal ideation but handed the bag to me without inspection, representing a severe safety failure.

Health Board Response

• Incident (25/02/2025) was reported via Datix.
• Investigation concluded that staff actions post-incident were appropriate.
• They cited my “settled presentation” and improved sleep to justify Section 17 leave and no search of deliveries.
• Recommendations included staff training on allergies and vigilance.

Recommendations 

• That the service reinforces awareness and all related actions associated to
  patient allergies, checking that all staff awareness and training is up to date.
• The service assesses and identifies opportunities for improvement, through discussion and training, staff awareness of variances in patient presentations and the identification of alternative warning signs.
• A review of adherence to documentation and record keeping policies,
  procedures, handover and effective MDT working to be undertaken. This is to ensure that accurate and consistent information is recorded and shared across the whole of the MDT and most importantly the patients.

My Response – Key Concerns

1. Superficial ‘Settled’ Does Not Equal Low Risk
   Presentations in EUPD with severe suicidal impulsivity fluctuate rapidly; brief calm periods do not indicate safety.
2. Documented Suicidal Ideation Contradicts ‘Settled’
   Previous suicide attempts (wardrobe, fence) and family concerns were ignored.
   Sleep disturbances, pacing, refusal to eat, and other distress signs were overlooked.
3. Unsafe Section 17 Leave Decision
   Leave was approved without adequate consultation or risk assessment, ignoring objections from my mother, grandparent, and myself.
   Decisions contravened MH Act 2015 (Wales) Code of Practice and NHS Wales Mental Health Measure 2010.
4. Risk Assessment Misrepresented
   The Health Board cited policy 5:1 (search if risk indicated), yet explicit, documented high suicide risk should have prompted intervention.
   Justification based on absence of formal diagnosis is misleading.
5. Patient Blaming and Dismissed Distress
   My acknowledgment of impulsivity is used to shift responsibility, ignoring repeated dismissal of my distress by staff.
6. Harm and Trauma
   The incident was avoidable and contributed to avoidable trauma. This is not properly acknowledged in the findings nor are the full contributing factors (e.g. neglect by staff on ward by dismissing my symptoms) The reply focuses too much on the aftermath as opposed to how the incident itself could've been prevented. It also fails to consider the fact that policy itself could be broken.

Summary

• While reporting the incident and recommending improvements is positive, the Health Board fails to acknowledge preventable risk and breach of duty.
• Risk was ignored despite clear warning signs and previous suicide attempts.
• Being detained under Section 2 heightened the duty of care owed.
• The failure by the health board to recognise any wrong doing here gives me grave concerns that this severe safety breach could repeat itself. A death associated with failure to properly maintain patient safety in relation to items bought onto inpatient wards has already occurred.
   

Section 2 – Escape from Ward

Incident Overview

On 06/03/2025, I escaped the ward while actively suicidal. Nurses had left the office door open, allowing me to leave to act on impulse. Police located me and returned me safely. Staff were aware of my intentions through prior discussions with Dr. Provan.

Health Board Response

• Confirmed in Datix and clinical notes.
• Staff reportedly observed me attempting to exit - immediate actions taken included locating me and contacting police.
• Investigation focused on post-incident management rather than contributory factors.

Recommended actions

• Staff reminded to keep nursing office doors secured and ensure codes are not inadvertently observed
• The service assesses and identifies opportunities for
  improvement, through discussion and training, staff awareness of variances in patient presentations and identification of alternative warning signs.

My Response – Key Concerns

1. Failure to Prevent Escape
   The escape should have been preventable given known high-risk status.
   Leaving the office door open created a preventable security breach.
   Staff did not notice I had left immediately, taking several minutes to respond.
2. Dismissed Warning Signs
   Earlier attempts to leave and agitation were ignored.
   Nurses made judgmental comments instead of offering support.
3. Misrepresented Support
   Claims 1:1 support was positive; in reality, it was brief and ineffective.
4. Ignored Distress
   Agitation, anxiety, and prior behaviour were dismissed, while a family visit has been misrepresented as evidence of stability.
5. Breach of Safeguarding Standards
   Maintaining a secure environment and responding to escalating risk are fundamental duties, both of which were breached.

Summary

• The Health Board’s claim that the incident “could not reasonably have been prevented” is factually incorrect.
• Basic safeguards were not implemented, directly contributing to risk.
• Post-incident responses do not address preventable harm or associated trauma.

Section 3 – Unsecured Wardrobe Incident

Incident Overview

On 26/02/2025, I was able to move an unsecured wardrobe in my room in an attempt to harm myself. A health care assistant intervened, but no immediate safety measures were put in place afterward. I had ongoing suicidal ideation related to the wardrobe, which posed a direct danger to me.

Health Board Response

Four bedrooms had unsecured furniture due to phased anti-ligature program works.

• No prior incidents recorded on Datix, but the issue has now been rectified.
• Staff responded immediately when alarms sounded; anti-barricade doors were effective.
• The incident was not submitted via Datix.
• Clinical notes dismissed my behaviour as “attention-seeking.”

“The language used in relation to your presentation at this time was not appropriate, and for that, on behalf of the Health Board, I am sorry”

Recommendations included:

• Regular review of ward furniture and safety
• Staff training on trauma-informed care, person-centred approaches, documentation, and incident reporting
• Reinforce across the workforce the importance of incident reporting and
  incident investigation and identification and sharing of any learning.

My Response – Key Concerns

1. Overlooked Safety Risk
   Lack of secured furniture in the four rooms was not mitigated proactively, despite anti-ligature program work.
2. Dismissed Distress and Mischaracterised Behaviour
   Staff recorded my distress as “attention-seeking,” ignoring severity.
   Incident resulted in further suicide attempts and trauma.
3. Inadequate Support and Staff Neglect
   Staff were dismissive of my anxiety and suicidal ideation, worsening my distress.
4. Incident Reporting Failures
   The event was not submitted via Datix, preventing proper investigation and learning.

Positive Steps

• Rectification of the unsecured furniture is acknowledged.
• Formal apology for inappropriate language regarding my presentation.
• Staff training recommendations and ongoing monitoring are positive, but do not address prior breach of duty.

Summary

• Improvements and training are welcome, but the initial failure to secure high-risk furniture and dismissive staff responses exposed me to preventable harm.
• Reflects a continued pattern of inadequate safeguarding and support for patients in acute distress.

Section 4 – Denial of PRN Medication and Staff Unprofessionalism

Incident Overview

On 16/02/2025, I attempted to jump the fence. I informed nurses of my distress and requested PRN lorazepam. I was rebuked, told I was not anxious, and denied access to my prescribed medication. My mother raised concerns with nurse Stephanie Williams, who misrepresented the situation and provided false information.

Health Board Response

• Incident confirmed in notes, not reported via Datix.
• Staff described me as “aggressive” and “demanding PRN medication,” eventually giving Promethazine.
• Acknowledged miscommunication regarding PRN medication, with an apology issued.
• Nurses cited alternative coping methods and addiction concerns.
• MDT documented suspected EUPD, GAD, and ASD screening

My Response – Key Concerns

1. Mischaracterisation of Emotional Dysregulation – Terms like “aggressive” misrepresent my crisis and contradictory notes ignored distress symptoms.
2. Failure to Administer PRN Medication Appropriately – PRN lorazepam often not given when clinically needed; Promethazine administered late and only after my request.
3. Dismissal of Anxiety – Told to “use techniques” without guidance and support was insufficient.
4. Unprofessional and Misleading Staff Conduct – Nurse Stephanie Williams lied to my mother, undermining trust.
5. Inadequate Documentation and Reporting – Incident not submitted via Datix limiting investigation.

Health Board Recommendations

• Review model of care to embed trauma-informed, person-centred approaches.
• Improve MDT working practices and handover procedures.
• Enhance communication regarding PRN medications, alternatives, and addiction risks.
• Train staff to recognise alternative presentations of anxiety and agitation and provide individualised support.
   

Section 5 – Unprofessional Conduct of Nurse Stephanie Williams 

Incident Overview

On 21/04/2025, I left the ward as an informal patient and became highly suicidal while off-ward. Police had to return me to Ward F. My mother was present when I returned and was distressed by the incident.

During this time, nurse Stephanie Williams:

• Spoke to my mother in a hostile and dismissive manner, preventing her from raising factually correct points regarding my care.
• Attempted to blame my mother for the incident.
• Showed little empathy, caused additional distress, and told my mother to leave.

Following this, I learned that nurses allegedly discussed my mother negatively and claimed she “tipped a table towards staff,” which is false:

• My mother has a physical disability (ileostomy bag) making this impossible.
• Police were present; their report confirms this did not happen.
• My stepfather was present; he and police could act as witnesses.
• This false statement is inaccurate personal data under GDPR, which must be corrected.

The false allegation and discussions caused me additional psychological distress, undermining trust in Ward F staff. Stephanie Williams’ conduct reflects a pattern of unprofessional behaviour, with potential risk to other vulnerable patients.

Health Board Response

• Incident recorded in Datix and clinical notes.
• Staff reported I was informal, and no risks were identified prior to leaving.
• Staff contacted police after I reported being in crisis near train tracks.
• Mental Health Act Section 136 assessment conducted upon return.
• Notes stated family members were "aggressive" and mother “upturned a table,” which is false - contradicted by police report.
• Apology issued for heated arguments and communication breakdowns.

Recommendations include:

• Sharing learning regarding engaging and de-escalating incidents involving patients and families.
• Reviewing parent/carer engagement.
• Re-circulating HB values, behaviours, and professional standards.
• Training in de-escalation and diffusion strategies.
• Reviewing information shared with patients/families regarding expected behaviours.
• Appropriate and proportionate action to be taken regarding employee conduct

My Response – Key Concerns

1. False Allegations and Misrepresentation
   Nurse Stephanie Williams falsely accused my mother of aggression, contradicted by police including their own report and witnesses.
   This constitutes inaccurate handling of personal data under GDPR and must be corrected.
2. Dismissive and Hostile Conduct
   Stephanie rebuked my mother, dismissed factual concerns, and heightened my distress, contributing to suicidal ideation.
3. Breakdown of Trust and Patient Safety
   Staff statements that my about my mother exacerbated my distress, and directly contributed to a breakdown of trust in Ward F staff.
4. Inadequate Support and Professional Standards
   The Health Board’s response apologises for “inconsistent communication” but does not directly acknowledge Stephanie’s false statements.
   Other nurses’ conduct should also be reviewed.
5. Systemic Issues
   Staff training, supervision, and reflective practice need reinforcement to support patients with complex mental health presentations.

Section 6 – Other Nurses’ Conduct and Resulting Suicide Attempt

Incident Overview

After I raised the inaccuracy of the false allegation made by Stephanie Williams, I was told by another nurse that my “relationships with staff had broken down completely.” This was an inappropriate and harmful statement to make to a vulnerable patient.

This left me feeling unsupported and hopeless. That evening, I attempted to hang myself with a curtain around my neck. Nurses entered the room during this attempt. This incident is documented in my notes (“curtain around neck”), despite the Health Board claiming they could not find any record of it in Datix.

Concerns with Staff Conduct

• Patients should never be told they have “broken down relationships” with staff — this is unprofessional and damaging.
• My attempt to hang myself was triggered directly by staff comments, yet the incident was not properly reported.
• Other nurses’ conduct, not just that of Stephanie Williams, requires formal investigation.

 Health Board Findings

• The Health Board state they were unable to find any record of my hanging attempt.
  Correction: It is recorded in my clinical notes, witnessed by staff.
• They acknowledge a “breakdown in your relationship with staff” was referenced in notes.
• They admit I was given inconsistent communication and apologise for this.

My Response

1. The Health Board’s claim that no record exists is inaccurate — this undermines the credibility of their review.
2. Staff actions contributed to my suicide attempt, which represents a serious failure in duty of care.
3. Accountability is needed not only for Stephanie Williams, but also for other staff who failed in professionalism.

 Health Board Recommendations (quoted from reply)

• “For the service to review the current support provision for Ward staff, to ensure that all staff have access to reflective practice, clinical supervision and focussed training opportunities, particularly relating to effectively working with and supporting patients with complex presentations. If deficits are identified appropriate steps should be taken to enhance the levels of support.”
• “For confidentiality reasons it is not appropriate to share information relating to any investigation relating to any individual or group of employees. However, it is important to give assurances that any concerns regarding the conduct or behaviour of any member of staff is taken extremely seriously and where there are concerns appropriate and proportionate action is taken.”

 My Position on Recommendations

• While reflective practice and supervision are important, this case also demonstrates the need for:
• Mandatory Datix reporting of all suicide attempts/self-harm incidents.
• Specific training in trauma-informed communication, ensuring staff avoid statements that worsen patients’ conditions.
• Active investigation into the conduct of multiple nurses, not limited to generalised “learning.”

Section 7 – Conduct of Psychiatrist Dr Robertson

Incident Overview
I wish to address the shocking professionalism and negligence of Dr Robertson during my admission. Her manner in meetings was not only unhelpful but left me and my mother feeling worse off and more distressed.

Examples include:

• On multiple occasions she told my mother “to get out” of meetings when my mother questioned why agreed care plans were not being followed.
• When discussing my self-harm, Dr Robertson flippantly said “we’ll have to look into making you homeless then.” A psychiatrist has no such authority, and this comment was profoundly damaging. It left me very emotional, forcing me to leave the room to calm down.
• She also told my mother she had “come to the reality that I could kill myself and won’t get any help.” This comment traumatised me and directly contributed to a serious suicide attempt while I was on leave. I repeatedly replayed this remark in my head, even during mindfulness exercises that were meant to help me cope.
• When I returned to the ward after that leave, she remarked, “we predicted you’d be back,” showing she anticipated another suicide attempt yet still allowed me to remain in the community.
• She also dismissed a previous escape attempt, stating “you never escaped from the ward.” This was factually incorrect — both ward notes and police records prove I did escape and had to be returned by intervention. Such a lack of awareness shows she was not properly reading my records, which raises serious concerns about how she could make safe clinical judgments.
• Even other nurses commented to me about Dr Robertson’s mannerisms, confirming that her approach was widely seen as flippant and dismissive.

Concerns

• These comments were not appropriate, professional, or therapeutic — they were harmful, dismissive, and contrary to NICE guidelines, which require care to be delivered in an atmosphere of hope and optimism.
• Dr Robertson’s conduct escalated my risk and contributed to a near-fatal suicide attempt.
• This is not an isolated issue: I am aware of other serious cases, including a coroner’s ruling of neglect where Dr Robertson was implicated. I also believe there has been at least one other recent patient death under her care, and another individual ended up in prison after she dismissed their suicide attempt and discharged them (to be confirmed).

 Health Board Findings

• They confirmed that notes record a discussion about homelessness “due to potential strain on family relationships” and suggested “standards of documentation could be improved.”

My response: This excuse is not acceptable. The comment was made in a meeting, witnessed by both me and my mother, and it caused significant harm. It was made due to my mother raising the fact that my leave had broken down as I was too unstable to be home – instead of recognising the fact I needed to return as had been promised by Dr Provan - she made this highly dismissive comment. The issue is not documentation but Dr Robertson’s inappropriate conduct.

• They acknowledged I attributed a suicide attempt to these comments in discussions, but claimed there were “no entries in notes” referring to this.

My response: This is inaccurate. The suicide attempt and the impact of Dr Robertson’s words are clearly recorded in my mental health assessment following the attempt, and staff witnessed my distress immediately after the meeting.

• They state they cannot share details of any action taken against an individual employee but assure that concerns are “taken extremely seriously.”

My response: This is insufficient. Dr Robertson’s conduct has already been linked to failings and coroner reports. Proportionate action must include formal investigation and disciplinary review.
 
Health Board Recommendations (quoted from reply)

“The service should review the training needs of all staff in relation to recognising alternative, varied presentations of anxiety and agitation and the importance of individualised and trauma informed care principles, particularly following all clinical review meetings with patients.”

• “The service should revisit documentation and record keeping training across all disciplines.”
• “It should also revisit/assess training needs, in relation to effective and appropriate communication, working in partnership with patients, their families and carers.”

My Position on Recommendations
While I support the proposed improvements in training, record keeping, and communication, these alone are not sufficient. Dr Robertson’s repeated harmful comments, dismissive manner, and failure to ensure safe care warrant:

• A formal disciplinary investigation into her conduct, not just additional training.
• Assurance that psychiatrists are held to the same trauma-informed standards expected of nurses and ward staff.
• Independent oversight, given that multiple patients and families have reported similar harm under her care.

Section 8 – Concerns Regarding Psychiatrist Sian Heke and Mental Health Act Assessment

Incident Overview
During a Mental Health Act (MHA) assessment in which psychiatrist Sian Heke was present, I believe the process was conducted unlawfully due to coercion and misinformation.

• I was incorrectly told that if detained under Section 3 of the MHA, I would never be able to pursue a career in pharmacy or travel abroad.
• This information was factually incorrect and discriminatory. In reality, medical students and other professionals have gone on to careers in medicine and pharmacy following previous detentions under the MHA once stable.
• By failing to present the accurate, positive perspective — that treatment could still lead to recovery and professional opportunities — I was placed under unlawful coercion in my decision-making.
• The coercive nature of this misinformation prevented me from fully disclosing my suicidal thoughts during the assessment. I did, however, state suicidal ideation if I were to leave hospital. Despite this disclosure, I was not detained, and shortly afterwards I made a serious suicide attempt while on leave, exactly as I had warned during the assessment.
• Following the assessment, it was wrongly entered into the system that I would not be allowed leave despite being given informal status. This amounts to de facto detention, which is unlawful. Only when I raised this with nurses was the decision reversed. If the team believed I could not safely have leave, then I should have been detained under the law, not placed in an informal status with leave restrictions.

Concerns

• The assessment was compromised by incorrect and coercive information.
• My safety was not safeguarded despite clear disclosure of suicide risk.
• The subsequent decision to restrict leave while maintaining informal status was legally unsound and an example of de facto detention.
• If staff believed I needed detention, they should have acted under the MHA rather than applying restrictions without lawful authority.

Health Board Findings

• They stated psychiatrists must follow guidelines and document decisions clearly.
• They claimed there was “evidence of a robust MHA assessment,” with consideration of risks, therapy options, and referrals to Community Mental Health Teams, and that I had “agreed to remain as an informal patient.”

My response: This ignores the fact that I was told I would never be able to do pharmacy if sectioned, which was coercion. Documentation cannot excuse misinformation. Witnesses to the assessment should be interviewed.

• They noted it is a legal requirement to explain the implications of Section 3 detention and said these discussions were documented.

My response: I do not dispute the need for discussion, but it must not be coercive or based on false and discriminatory information.

• They stated MDT discussions about me remaining informal but not having leave were made in line with policy CID3190.

My response: This is contradictory. If the risk was high enough to restrict leave, detention should have been applied. Instead, I was placed in an unlawful position of de facto detention.
 
Health Board Recommendations (quoted from reply)

• “After carrying out my investigation, I was unable to find any failings in care which amount to a breach of duty.”
• “For confidentiality reasons it is not appropriate to share information relating to any individual employee. However, it is important to give assurances that any concerns regarding the conduct or behaviour of any member of staff is taken extremely seriously and where there are concerns appropriate and proportionate action is taken.”

 My Position on Recommendations

• The finding that there were “no failings in care” is unacceptable. The misinformation I received directly influenced my disclosure, risk assessment, and subsequent suicide attempt.
• The actions taken amounted to unlawful coercion and illegal de facto detention.
  It is not sufficient to rely on confidentiality assurances; this conduct must be formally investigated.
• Independent oversight is required to ensure MHA assessments are carried out lawfully, factually, and free from coercion, particularly when patients are highly vulnerable.
   

Section 9 – Concerns Regarding Dr. Provan’s Departure and Care Coordination Failures

Incident Overview

• I was initially under the care of Dr. Provan, who was my named psychiatrist and who covered most of my treatment during my admission.
• In a meeting, Dr. Provan clearly promised that I would be allocated a care coordinator prior to discharge. This was an important assurance, given my diagnosis and the high necessity of coordinated care to manage my condition.
• Despite this, nurses repeatedly told me I “might not get a care coordinator,” which contradicted what I had been told directly by my psychiatrist.
• The sudden departure of Dr. Provan caused me significant psychological distress. I was not informed in advance that he would be leaving, nor was I told before attending my scheduled review that Dr. Robertson would instead be covering my care.
• According to NICE guidelines, “changes to the care of individuals with EUPD should be planned and coordinated.” This was not followed. Instead, I was surprised to discover, on the day, that my psychiatrist had left with no prior communication or preparation. This represented a breakdown in both planning and trust at a critical stage of my treatment.

 
Concerns

• Clear breach of NICE guidance around planned and coordinated changes in care.
• I was given mixed and contradictory information about care coordination, despite promises from my psychiatrist.
• The sudden, uncommunicated transfer to a new psychiatrist left me destabilised, anxious, and distressed, as I had worked hard to build trust with Dr. Provan.
• Lack of clarity and communication about the care coordinator referral pathway undermined my treatment and discharge planning.
   

Health Board Findings

• They admitted there were “inconsistencies and communication issues” between the MDT, community team, and myself in relation to assessment, treatment, and intervention. They apologised for this.

My response: Apology appreciated — but this represents more than a communication issue. It directly undermined my ability to trust staff and feel safe.

• They acknowledged a “lack of shared clarity and understanding” around the care coordinator process, particularly for patients admitted under Section 2 of the MHA.

My response: Correct process may exist, but in my case it was not followed.

• They admitted “deficits in how referrals/plans were undertaken and communicated” and apologised again.

My response: Again, I appreciate this acknowledgment — but these deficits are significant and had serious consequences for my mental health.

• They noted that at the end of February 2025, Dr. Provan was diverted to another service and Dr. Robertson took over on an interim basis. They acknowledged this was handled poorly, particularly in terms of how it was shared with me, and apologised for the distress caused.

 Health Board Recommendations (quoted from reply)

• Review the model of care to ensure it supports trauma-informed, person-centred approaches.
• Complete a training needs analysis across all disciplines, focusing on trauma-informed care and person-centred approaches.
• Review the care coordinator referral pathway to identify learning and changes needed.
• Share findings of this review across all disciplines to ensure consistent communication with patients.

My Position on Recommendations

• I appreciate the apologies and the acknowledgement of poor communication.
• However, the failure to follow NICE guidance around planned transitions and the failure to ensure a promised care coordinator represent more than communication deficits — they are systemic failings that compromised my care and safety.
• The recommendations are positive, but they must be actioned transparently with evidence of change. Patients must not only be given apologies but must also see that the system learns from these mistakes.

Section 10 – Refusal of Return to Ward Despite Agreement with Psychiatrist

Incident Overview

• During a review, Dr. Provan promised me and my mother that if there were any concerns or deterioration in my mental state during trial home leave, I would be able to return to the ward at any time.
• After several days of leave, I became very distressed at home and developed suicidal urges, specifically the intent to self-harm by pouring boiling water over myself.
• Myself and my family rang the ward requesting immediate return, in line with the agreed plan.
• Stephanie Williams, a nurse on the ward, refused my readmission despite the explicit agreement with Dr. Provan.
• This refusal directly placed me at risk, undermined the plan I had trusted, and caused me significant psychological distress.

Concerns

• Contradictory information from nurses versus psychiatrist’s plan.
• Breach of trust and safety — my psychiatrist had promised I would not be left in danger at home if my condition worsened.
• Nurses’ exercise of discretion here contradicted medical direction, resulting in risk escalation rather than safeguarding.
• Such contradictions create an unsafe environment where patients cannot trust that treatment agreements will be upheld.

 
Health Board Findings

• They accepted that there was “inconsistent and differing information communicated” to me regarding readmission, and issued an apology.

My response: I appreciate the apology, but this inconsistency represented a direct safety risk and was more than a communication issue. It undermined my confidence in being safe while on leave.
 
Health Board Recommendations (quoted from reply)

• Review the model of care to ensure it supports trauma-informed, person-centred approaches.
• Undertake a review of current adherence to the policy for readmission of informal patients on trial home leave and implement necessary changes.
• Assurance again that concerns about staff conduct are taken seriously and addressed proportionately. 

My Position on Recommendations

• I welcome the specific recommendation to review adherence to the trial leave readmission policy — this is crucial, as my case shows this policy was not followed consistently.
• However, it is vital that this review results in concrete, enforceable safeguards to prevent nurses from contradicting psychiatrists’ instructions in situations where patient safety is at immediate risk.
• Trauma-informed and person-centred care requires consistency and reliability. Mixed messages and discretionary refusals in crisis moments actively worsen outcomes and can lead to self-harm or suicide attempts. 

Section 11 – Failures in Communication and Delay in Referral for Care Coordination/DBT

Incident Overview

• Whilst on leave, I was repeatedly called back and forth to meetings on Ward F where I was told by staff that my referrals for care coordination and DBT were “being chased.”
• Prior to his sudden departure, Dr. Provan promised both myself and my mother that I would have a care coordinator in place prior to discharge. This promise was not upheld.
• Despite this, nurses then repeatedly told me that I “might not get a care coordinator,” which directly contradicted what had been promised by my psychiatrist.
• When I and my advocate contacted the Community Mental Health Team directly, we were informed that their position was that I needed to be discharged before assessment could take place. This shows that nurses were not actually in communication with the CMHT, as claimed. If they had been, this position would have been relayed to me clearly during meetings, sparing me weeks of unnecessary distress.
• Additionally, I am not satisfied that nurses accurately or urgently communicated the high level of risk I was experiencing (self-harm urges and multiple suicide attempts) to the CMHT.
• A generic care and treatment plan was created by nurse Holly which incorrectly recorded that there were “no psychological concerns,” despite my diagnosis of EUPD and my repeated suicidal crises. This remained uncorrected for several weeks, delaying access to the care I urgently required.

Concerns

• Inconsistent and contradictory communication between nurses, psychiatrists, and community teams.
• Delay in essential treatment due to misrepresentation of my psychological risk and poor quality of care plans.
• Breach of trust caused by failure to uphold a psychiatrist’s clear commitment (care coordinator prior to discharge).
• Significant psychological distress caused by being given conflicting information week after week, which worsened my anxiety and suicidality.
• Direct risk to life due to delayed access to care coordination and specialist treatment. (Uncertainties did cause further attempts on my life as a result)

 Health Board Findings

• They acknowledged there was evidence of “inconsistent and differing information communicated in relation to referrals made and required assessments”, and issued an apology.

My response: I appreciate this acknowledgment, but inconsistent communication in this case was not just an inconvenience — it placed my life at risk by delaying essential interventions while I continued to struggle with suicidal thoughts and self-harm.
 
Health Board Recommendations (quoted from reply)

• Undertake a detailed review and update of the assessment and allocation of care coordinators, specifically in relation to discharge pathways from inpatient services.
• Assess training needs and develop a training plan for all staff on:
  Co-production and completion of high-quality Care and Treatment Plans
  Patient-centred safety planning
  Risk assessments (Wales Applied Risk Research Network framework)
• Assess and improve training, awareness, and mutual understanding of roles and responsibilities between CMHT, CRHTT, and inpatient services — particularly regarding Personality Disorder pathways and treatment options.

 My Position on Recommendations

• I strongly agree that there needs to be a detailed review of the care coordinator referral pathway. My case shows this pathway is not functioning as intended, resulting in unacceptable delays.
• Training on care and treatment plans is urgently needed. It was wholly inappropriate that my initial plan recorded “no psychological concerns” when I was acutely suicidal and diagnosed with EUPD. This is a serious error that could have had catastrophic consequences.
• It is vital that staff are trained to communicate clearly, consistently, and honestly with patients. Being told contradictory and inaccurate information repeatedly caused me unnecessary suffering.
• Above all, communication between inpatient and community teams must be improved so that patients are not misled about what is happening with their referrals, and so that the true level of risk is always conveyed.

Section 12 – Failure to Provide Access to Medical Records (GDPR Breach)

Incident Overview

• I submitted a formal subject access request (SAR) for my medical records in order to reassure myself and to evidence the concerns I was raising.
• Under GDPR and the Data Protection Act 2018, I am legally entitled to my personal medical data within 28 days of request.
• This deadline was not met. When I contacted the office that handles medical records, I was informed that Ward F had communicated that I could not access my records whilst I was an inpatient.

This information was false. I had been given clear confirmation in a meeting by Dr. Siddiqui that I was entitled to access my records. Therefore, the restriction imposed by Ward F was not only factually incorrect but also unlawful.
As a result, I was denied timely access to my personal data, which significantly delayed my ability to evidence my concerns and undermined trust in the service.

 Concerns

• Serious breach of the 28-day statutory timeframe under GDPR.
• Inaccurate information communicated by Ward F, directly contradicting confirmation from my psychiatrist that I was entitled to access my records.
• Concerns that nursing staff may lack awareness of GDPR obligations, which is unacceptable given the critical importance of patient data rights.
• The delay obstructed my ability to safeguard myself by evidencing my concerns at the time they were most urgent.
   

Health Board Findings

• The investigation found that my SAR was held up in the inbox of a consultant who was absent from work at the time, which caused the delay.
• The Health Board acknowledged that the 28-day timeframe was breached and issued an apology.
• They confirmed that I have since received my records (from Ward F's care)

 
Health Board Recommendation (quoted from reply)

• The service should review processes to ensure that all subject access requests are submitted and actioned in a timely manner.

My Position on Recommendation

• While I welcome this recommendation, it does not go far enough. My case demonstrates not only a delay in processing but also misinformation being given by Ward F staff which misrepresented my legal rights.
• It must be ensured that all staff, including nurses, receive training on GDPR, patient data rights, and subject access requests so that misinformation of this nature is never communicated to patients again.
• The breach of GDPR rights is a serious legal failing in addition to being a professional and ethical failing, and the Health Board must treat it with the gravity it deserves.

Section 13 – Transition to Cefn Coed and Ongoing Concerns Regarding DBT and Care Coordination

Incident Overview

Due to the lack of trust and ongoing issues with Ward F, I was moved to Cefn Coed Hospital on 23rd April. I was placed under undergoing extended assessment by the Community Mental Health Team (CMHT) and had been told I was accepted for Dialectical Behaviour Therapy (DBT), which has been consistently recommended by multiple psychiatrists as the treatment I require.
 
Concerns

• I was not advised at the time of any DBT pathway or that access required a multi-step referral/assessment process. This only came to light after I began challenging the inconsistencies.
• The extended assessment period within CMHT was unnecessary and added to my distress, given that I had been under ongoing psychiatric assessment since February.
• Several psychiatrists had already clearly stated my need for DBT, yet communication delays and mismanagement meant that this treatment was not initiated in a timely manner.
• I remain concerned about issues in my treatment and denial of appropriate care.
   

Health Board Findings

• There were inconsistencies in what was documented and communicated to me in relation to DBT and care coordination referrals. This understandably caused me confusion, uncertainty, and anxiety. For this, the Health Board issued an apology.
• It was acknowledged that DBT is a specialist intervention that requires assessment and referral via the established DBT pathway.
• The Health Board stated that referrals had been submitted and that I was undergoing extended CMHT assessment, with an offer made for an emotional regulation group. As I have raised before, this group is too generic and unsuitable for my complex needs. I require full DBT, not a diluted intervention.
• They noted my “positive experience” at Cefn Coed and that the team is now reviewing my care and treatment needs in preparation for a proper treatment plan.
   

Health Board Recommendations (quoted from reply)

• Assess/review training, awareness, and mutual understanding of roles and responsibilities and connectivity between CMHT, CRHTT, and inpatient services – particularly around Personality Disorder pathways and treatment options.
• Ensure all staff are aware of the importance of clear, consistent communication and the serious impact on patients when this is absent.
• Undertake a review of the care coordinator referral pathway against current policy and share findings across all disciplines.
• Ensure that all disciplines are reminded of the importance of adhering to existing agreed clinical care pathways.

My Position on Recommendations

I welcome acknowledgment of the distress caused by inconsistent communication, but I must stress:

• I was never advised of the DBT pathway at the time, which reflects a serious gap in communication and transparency.
• The extended assessment within CMHT was redundant and avoidable, prolonging my distress unnecessarily.
• A generic Emotional Regulation Skills Group is not an adequate substitute for DBT.
• Offering this instead of DBT risks further delays in accessing the specialist therapy that multiple psychiatrists have confirmed I need.

I therefore request that the Health Board ensures I am placed on the full DBT pathway without further delay and that communication regarding this process is clear, consistent, and upheld by all professionals involved in my care.

Complaint Conclusion and what I asked for:

I would like an investigation into the poor safety standards at Ward F, incompetence of nurses and psychiatrists in terms of their communication and compliance to nursing and medical standards expected of mental health nurses and psychiatrists.

I would like it to be acknowledged that my care has not been as would be expected and that my life was put at risk due to the poor care I received to date. If appropriate I would like staff to be apprehended for their lack of care towards myself with appropriate disciplinary action taken if deemed necessary as well as rebriefing regarding compliance to standards.

I want to know what changes will be made in Ward F based on my experience as I am concerned that other patients with mental health difficulties like myself will also not get the help that they require and be appropriately safeguarded whilst under the care of the ward. I want assurance that I will now be having the DBT therapy that I require from the community mental health team as I still remain hesitant regarding whether the support I require will be implemented.

I also need it to be ensured that I do obtain a care coordinator as Dr Provan and multiple social workers who have been in mental health assessments with myself have stated I require. My anxiety regarding discussing my mental health has also increased due to my negative impression of the mental health services to date.

NICE guidelines for the treatment of borderline personality disorder state ‘Patients should be treated with dignity and respect’ which has clearly not been the case given my experience. I want an apology for all issues raised. 

Health Board Reply / Findings:

It is difficult to conclude any findings as this part of your complaint largely focuses on your overall dissatisfaction on the service provided. DBT, as stated earlier, is accessed via an agreed clinical pathway.

Therefore, I am not able to comment upon your suitability or eligibility to access this intervention at this specific time. The DBT clinical pathway is designed to ensure that this intervention is delivered to the right people, at the right time, as it can potentially cause harm in some cases, under certain circumstances.

Actions / Recommendations:

After carrying out my investigation, I was unable to find any failings in care which amount to a breach of duty. I wish to thank you for speaking out and sharing your concerns with us and I hope that this outcome summary goes some way in providing you with assurances that we are and will continue to take action by further reviews/investigation, to ensure that all aspects of your concerns are concluded.

I now expect the service to develop a robust and comprehensive action plan that fully reflects the recommendations outlined in this letter.

Response to Findings & Recommendations:

The reply to my complaint conclusion fails to address or acknowledge the specific failings of Ward F staff that directly endangered my safety, including refusal to readmit me during a crisis, inconsistent messaging about my care, and ongoing denial of DBT therapy.

It avoids acknowledging the specific issues I raised regarding poor communication, refusal to provide care as promised by Dr. Provan, and repeated delays and conflicting information that put my safety at risk. On behalf of the Health Board, they state they are very sorry the care I received was not to the expected standard.

The Health Board’s claim that “no failings in care amount to a breach of duty” does not reflect the documented evidence of risk to my life, breaches of NICE guidelines, or failure to follow clinical standards. The statement regarding the DBT clinical pathway ignores that multiple psychiatrists and social workers had already confirmed my need for DBT; the pathway itself was has not been followed or communicated correctly, which caused avoidable harm and distress.

Call to Action:

• The Health Board must formally acknowledge the specific failings in duty of care at Ward F.
• A robust action plan must be developed detailing changes in ward protocols, including staff training, supervision, and adherence to care pathways for high-risk patients.
• Assurance must be provided that I will receive DBT therapy as already identified as necessary by Dr. Provan and multiple social workers. The ongoing denial of therapy must be reversed by the health board.
• Staff responsible for repeated failures in communication and safety should be reviewed for appropriate disciplinary or retraining action, including refresher training on NICE guidelines and safeguarding duties.
• A formal written apology should be issued acknowledging the harm caused and the failure to treat me with dignity and respect.
• Measures must be implemented to ensure future patients are safeguarded from similar systemic failures at Ward F.
• My 120-page complaint letter with additional context must be responded to as this draws on all guidelines breached, with supporting evidence directly from my medical records. I have been informed by the investigator she will be reviewing this next.

The response as it stands is inadequate, fails to fully acknowledge the specific incidents of poor care, and does not provide assurance that systemic changes will prevent harm to other patients.

Conclusion

The Health Board’s response completely fails to acknowledge the clear breach of duty in my care. Their claim that no harm was caused and no duty was breached is unacceptable, particularly given that I was a highly vulnerable patient, sectioned, and allowed access to Brazil nuts whilst in crisis. Their response is full of excuses, avoiding accountability for serious lapses in care. The NHS ‘putting things right’ complaints procedure has failed me, as it allows staff to evade responsibility while offering only vague assurances of “lessons learned” with no evidence of real action. This petition is needed because Ward F has repeatedly demonstrated unsafe practices, poor communication, and failures in professional standards that put lives at risk. I will continue to push for genuine change, demand accountability, and speak up until concrete disciplinary measures are taken, transparent reforms are implemented, and all staff are retrained to meet the standards required for mental health care. This is not just about my experience—it is about safeguarding all vulnerable patients in the future, ensuring they are treated with dignity, respect, and appropriate professional care.

I will also be publishing a more in-depth analysis soon, breaking down specific sections of my care and systemic failures. My website is work in progress, and I will be sharing further updates regarding negligent discharge of a fellow patient, an overdose attempt of another patient that I had to intervene in, and a threatening letter I received this week from health board management on the back of my complaint reply. There is much more to come, and I will continue to shine light on the state of Swansea Bay Mental Health Services which has been brushed over and overlooked for too long until meaningful change is enforced.

Many thanks for the continued support. I will be in touch with further updates over the upcoming week. 

All the best,

Jacob Robertson