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Spotlight 2/3

Patient and caregivers’ experiences with mental health care

Patient Ombudsman dealt with more than 400 complaints involving mental health and addictions services in 2023/24.

A doctor puts their arm around a patient as a dog looks up at them.

This constitutes approximately 10% of all complaints; almost 90% of mental health complaints were about care in hospitals.

The rest were mostly about services outside of Patient Ombudsman’s jurisdiction, including challenges with primary care, specialist care by psychiatrists, and community mental health and addictions programs and services.

Two-thirds of the people who contacted Patient Ombudsman in connection with mental health and addiction care were patients who expressed concerns about their own care. The remaining third were largely complaints received from patients’ family members, often expressing concerns that they were not engaged to help inform the patient’s care plan and discharge. This was a particular concern if the discharge plan involved the patient returning to the family member’s home, especially when the patient had a history of self-harm or physical aggression (see the investigation summary, “Discharge of a vulnerable youth.”)

Patient experience

The patient contacted Patient Ombudsman to express concern about the mental health care they received in a hospital emergency department. On one occasion, the patient was admitted for treatment as an involuntary patient and on a second occasion the patient was held for several hours and discharged without treatment. On both occasions the patient reported being physically and chemically restrained. The patient had a care plan in place with another hospital that was working well, and they were open to the two hospitals sharing information to ensure they received the care they needed in the future.

What we did

Patient Ombudsman contacted the hospital’s patient relations representative and shared the patient’s wish for a meeting with patient relations and the treating physician to share their experiences. Patient Ombudsman also suggested that the patient would benefit from having a family member or friend attend the meeting to provide support. The patient relations representative agreed to contact the patient to arrange the meeting.

Other characteristics of complaints about mental health and addictions services include:

23% involved concerns about involuntary admissions*

*including disagreements with assessments, medication choices and privileges (access to showers, access to phones).

16% described concerns about care in emergency departments.

14% of people reported unsafe or poorly planned discharges.

14% expressed concerns that the patients’ suicidal ideation or risks were not adequately addressed, or that the patient had died by suicide shortly after discharge.

11% described the use of force by hospital security.

7% of complainants reported that medical problems, sometimes serious health issues, were not properly assessed because they were attributed to the patient’s mental health issues.

5% described prolonged or unjustified use of physical or chemical restraints.

Many of the concerns dealt with clinical assessments and decision-making and required referrals to health professions regulatory colleges. In some cases, patients and caregivers were seeking financial compensation or punitive actions in relation to their complaints, and we made referrals to free legal support resources to enable them to obtain advice about their legal options. In about 10% of cases about mental health care, the complainants could not be reached for follow-up or chose to withdraw their complaints after the initial contact with Patient Ombudsman.

In addition to our work resolving individual complaints, Patient Ombudsman will continue to monitor complaints about patients’ and caregivers’ experiences with mental health and addictions services to identify trends and identify opportunities for improved fairness.