Health board fails again to deliver medical records on treatment of suicide-risk teenager

Martin Shipton

A health board has apologised for further delays in disclosing the medical records of a teenager whose multiple suicide attempts raised concerns about the quality of treatment at a mental health unit.

In June 2023, Nation.Cymru published a special report about the concerns of service users and their families relating to the Hafan y Coed mental health unit at Llandough Hospital, run by Cardiff and Vale University Health Board.

The article followed a protest outside the hospital undertaken by around 30 relatives of patients.

A review was commissioned into the care provided by Hafan y Coed to Anya Del Amo, now 19, after an incident when she was handcuffed. The review identified 30 shortcomings relating to the way she was treated while an in-patient at the unit:

One of the shortcomings stemmed from the failure to monitor Anya properly while she was a patient on Cedar ward, where CAMHS [Child and Adolescence Mental Health Services] policy states that “the young person is under constant observation in the presence of adults … Staffing for CAMHS close observations will be additional to Cedar ward’s usual/safe staffing levels.”

‘Escalating risk’

The report stated: “On review of the notes, it is documented on several occasions that staff were unfamiliar with the CAMHS policy and staff appeared to be unable to identify escalating risk and rationalise it in the context of the policy. Ms Del Amo was engaging in escalating high risk behaviours and staff whilst immediately dealing with the risk i.e. cutting off ligatures, they permitted Ms Del Amo back into her room with the door closed and did not directly observe her. This appeared to escalate high risk behaviours which resulted in repeated episodes of restraint. This further exacerbated Ms Del Amo’s risk of deliberate self-harm becoming more dangerous and difficult to support on Cedar ward.”

Despite 29 further shortcomings being identified, the health board wrote to Anya’s father Scott Del Amo stating: “Following careful consideration by the health board’s Redress Team in June 2024, it was concluded that although the above failings in care were identified during the course of the incident investigation, the health board does not consider that any of these failings will have directly caused, or materially contributed to, any harm to your daughter.”

Failures

In January Mr Del Amo told us: “Clearly the failures outlined in the review are very disturbing. We don’t accept that they caused Anya no harm.

“We want to see her medical records to cross-check them against the review findings as we consider whether to bring a lawsuit against the health board. I’ve been asking for them for a very long time. Senior managers have made repeated promises that the records would be handed over by particular dates, but they’ve failed to meet the deadlines.”

Ms Del Amo subsequently left Hafan y Coed and received treatment as an in-patient at a residential NHS mental health unit called Springbank in Cambridge, where she made considerable progress. She now has a baby, Luna, who is six and a half months old.

A spokesperson for Cardiff and Vale University Health Board apologised in early January for the delay in providing Anya’s medical records, saying it was taking “significantly longer than we would expect”.

We have spoken again to Ms Del Amo and her father.

Mr Del Amo said: “We have a legal right to see the medical records and it is disgraceful that we have still not been provided with them. There is no justification for the delay.”

‘Told off’

Ms Del Amo said: “I went to a meeting thinking there was going to be a review of my case, but I was told off for speaking to the media. I think that’s shocking.

“One of my complaints about Hafan y Coed was that they weren’t organising any activities or therapy sessions for patients like me, and that’s what a report published last October [by Healthcare Inspectorate Wales] said was still a problem. It’s such a contrast with the progress I made at Springbank.”

A spokesperson for Cardiff and Vale University Health Board, said: “We apologise sincerely for the delay the Del Amo family have experienced in accessing Anya’s medical records. Due to the complexities in this case it has taken significantly longer than we would have expected to provide the medical notes requested, combined with an administrative oversight on our behalf that has resulted in an unacceptable delay in our correspondence to Anya.

“We can confirm that a letter has been sent to Anya today and our teams will continue to liaise directly with the family on this matter.”