PSOW Individual Decisions

Miss A was dissatisfied with the handling of her complaint that Welsh Government’s Nest Scheme failed to register her boiler when it was installed. Miss A had to chase a response to her emails, and she said that her telephone calls were never returned. The Ombudsman decided that unreasonable delays had occurred in replying to Miss A’s correspondence, and her concerns had not been investigated or responded to as a formal complaint. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained Welsh Government’s agreement within 2 weeks, to offer Miss A an apology, and to investigate her concerns, remedying any issues identified.

Complaint that the Welsh Government had failed to take into account the safety of residents when implementing changes to the road and pavements where the complainant lives. ER agreed: The Ombudsman sought and gained the Welsh Government’s agreement to review the information provided by Mr A and reconsider if the complaint submitted falls within the scope of its complaints process. It agreed to provide Mr A with a formal response outlining the outcome of this review and an apology that he had not been informed of the decision not to consider his correspondence as a complaint. It also agreed that, if the review concludes that the complaint does meet the criteria for the Welsh Government’s complaints process, to provide Mr A with a full response to his complaint. The Welsh Government agreed to complete these actions within 4weeks.

Ms B complained about inpatient care and treatment provided to her husband in February 2025, in particular the management of his medication. The assessment found that the complaint response did not adequately address the concerns raised or qualifying liability, further to Welsh Government guidance. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to, within 2 months, fully respond to Ms B’s outstanding concerns, including qualifying liability and offer an apology for not having done so previously.

Mx M complained about a delay in the Student Loans Company responding to an appeal about a decision it had made. The Ombudsman cannot consider the issues relating to the appeal itself, as those issues fall outside of her jurisdiction (section 13(1)(b) of the Public Services Ombudsman (Wales) Act 2019). However, the Ombudsman found that there was a significant delay in Mx M receiving a response to the appeal (which was subsequently issued to Mx M after the complaint was submitted to the Ombudsman’s office). The Ombudsman said that the delay caused inconvenience to Mx M, and found that the appeal response offered no apology or explanation for the delay, causing further frustration to Mx M. The Ombudsman decided to settle the complaint without a formal investigation. The Ombudsman sought and gained the Student Loans Company’s agreement to apologise to Mx M and explain the reasons for the delay within 5 weeks.

Mr W complained about a delay in receiving a total knee replacement surgery from Swansea Bay University Health Board, which he had been waiting for since August 2019. The investigation considered whether Mr W’s waiting time for surgery was appropriately managed in line with the Welsh Government’s Rules for Managing Referral to Treatment Waiting Times, specifically when his waiting time clock was re-set in October 2023. The investigation found that Mr W’s waiting time clock was inappropriately re-set in October 2023. It found no evidence that a clinician had documented that Mr W was medically unfit to proceed with surgery. Mr W required a repeat scan, due to the amount of time he had been waiting, which confirmed his fitness to proceed. The decision to re-set the waiting time clock was also not communicated to Mr W and he only became aware when he made a complaint. As a result of the delay, Mr W had experienced pain, reduced mobility and ongoing frustration. Further to this, he is now in a position where he is not able to proceed with surgery and this opportunity has been lost. In January 2024, this office published 3 reports in the public interest in relation to the Health Board’s management of the waiting list for orthopaedic treatment. These reports found that in all 3 cases the complainants had been treated unfairly because of errors in the way the waiting lists for orthopaedic surgery were managed. One of the recommendations contained within those reports was that the Health Board should carry out an audit of its waiting list to establish whether any other errors had been made relating to the resetting of waiting list times or improper removal from the list. It is concerning that further errors have subsequently been found despite this audit having taken place. This raises concern about the reliability of the audit the Health Board undertook previously. The Health Board agreed to the following recommendations: a) Arrange for the Chief Executive to make an apolog

Ms C complained that a Welsh Government body had not provided an adequate response to her complaint about the conduct of a member of staff. The Ombudsman decided that the body did not have a complaints procedure in place. Whilst it had responded promptly when the complaint was first raised, the final response did not provide a clear outcome, leaving Ms C unsure whether her complaint had been taken seriously, upheld, or any action had been taken. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the agreement of the Welsh Government and the body to write to Ms C within 4 weeks to provide a clear outcome to her complaint and to publish a complaints procedure within 8 weeks.

Ms C complained that Care Inspectorate Wales had not acted impartially when it investigated and responded to her complaint. The Ombudsman decided that the Body’s investigation did not lack impartiality, but the response had not fully considered that there had been a breakdown in communication regarding the availability of training, which had caused Ms C unnecessary distress. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Body’s agreement to provide feedback to the staff involved, provide clarification to all staff regarding the availability of training and apologise to Ms C for how it communicated with her, within four weeks.

Mr A had complained about the way that Nest had unreasonably withdrawn his application for a replacement boiler to be installed at his property under the Welsh Government – Warm Homes Nest Scheme. Nest had initially informed Mr A that he was eligible for a replacement boiler under the Scheme in late 2023. However, it then withdrew the offer as Mr A lived in a Conservation Area. Nest believed that planning permission would be required for the work and that there would be insufficient time for it to obtain planning consent and to undertake the work before the Scheme closed at the end of March 2024. When Mr A complained about this matter, contact was made with the Local Planning Authority which promptly advised that planning permission was not required; the work could be done under Permitted Development rules. The Ombudsman was of the view that Nest had failed to properly establish whether planning permission was, in fact, required before closing Mr A’s application. That resulted in it being necessary for Mr A to purchase and pay for the installation of a boiler himself, which was an injustice. Instead of investigating this complaint, the Ombudsman obtained Nest’s agreement to, within 1 month, apologise to Mr A and reimburse him for the cost of buying and installing a replacement boiler. Nest also agreed to, within 3 months, undertake a review to ensure that no other applicants were disadvantaged in the same way.

Mr B complained that following a change in his circumstances, despite telephoning the Council at the end of September/beginning of October 2022 to make a payment arrangement he had not received a Council Tax (CT) bill for his previous address. He left the property in June 2022. He had been contacted by the bailiffs in 2024 in relation to outstanding council tax. The Council provided assurances to the Ombudsman that it would consider an affordable payment proposal from Mr B. It also referred to ways that Mr B’s CT debt and court costs might be reduced. The Ombudsman as part of an early resolution settlement arranged for the Council to send Mr B relevant CT invoices, including one that had been sent prior to Mr B leaving his property as well as other advocacy information. It also agreed to consider whether there were lessons that could be learnt from Mr B’s case around promoting earlier intervention, given the Welsh Government’s Council Tax Protocol.

Dr A submitted an appeal to Planning and Environment Decisions Wales (“PEDW”) in May 2023. Although it had been acknowledged as a valid appeal in October 2023, he complained that a Planning Inspector had still not been allocated and no progress had been made. Dr A had complained to PEDW in June 2024 but had not received a formal complaint response. The Ombudsman found that there had been significant delays and the appeal timetable was not met, due to a backlog of cases and pressure on resources. PEDW had taken steps to address this by appointing new inspectors and administrative staff and the appeal had now been listed for consideration. This had caused frustration and inconvenience for Dr A. The Ombudsman further found that although an update had been provided following his complaint, no formal investigation had been undertaken and a complaint response was not provided. The Ombudsman decided to settle the complaint without investigation. She sought and obtained PEDW’s agreement to, within 2 weeks, provide Dr A with a written apology for failing to investigate and provide a formal response to his complaint, and to provide him with a formal complaint response.

Mr X complained that Welsh Government had failed to resolve excess speeding in a 20 mph zone due to a lack of signage. Mr X also complained about the lack of plain English within the complaint response. The Ombudsman concluded that whilst the complaint response was appropriate in respect of its strategic decision, it lacked clarity and was not written in plain English. The Ombudsman said this had caused uncertainty, frustration, and inconvenience to Mr X. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained Welsh Government’s agreement to issue a further complaint response in plain English within 2 weeks.

Miss A complained that between February 2021 and January 2023, Hafod Housing Association (the HA) had not acted in accordance with its policy and procedure regarding her anti-social behaviour (“ASB”) complaints about parking and noise nuisance. In addition, concerning the ASB the HA had failed to take her disability into account and consider whether it was appropriate to make reasonable adjustments (“RAs”) under the Equality Act 2010. Finally, Ms A said that the HA did not handle her complaint in line with its complaint process and did not sufficiently address the ASB matters that she raised in its complaint response to her. The Ombudsman found that the HA had not always acted in accordance with its ASB policy and procedure, or indeed best practice as set out by the Welsh Government. She also identified that communication with Miss A could have been more effective than it was. In terms of record-keeping, the Ombudsman found that it was not always clear when contact was made or what the ASB management plan was in Miss A’s case. Inaccuracies in some of the responses provided by the HA were also not helpful. The Ombudsman noted that Miss A did not always return noise logs and there were periods where she did not report ASB complaints. There were also instances when the HA did take action. Despite this, shortcomings in the way the HA carried out its ASB policy and procedure, added to Miss A’s distress and caused an injustice. The Ombudsman concluded that the HA’s failings amounted to maladministration. In light of these shortcomings, to that extent only, this part of Miss A’s complaint was upheld. The Ombudsman identified that there was a lack of meaningful engagement shown by the HA in Miss A’s health issues. This led to missed opportunities for it to consider reasonable adjustments at an early stage. The Ombudsman also noted the HA’s failure to identify and acknowledge this as an issue in its responses to the complaint, including to the Ombudsman’s office. The Ombudsm

Mrs A complained that the Council had failed to ensure a safeguarding complaint she made in November 2023 following harm to her child at his primary school was fully investigated and responded to. The school had declined to investigate her complaint as it was of the view that it was substantially the same as an earlier complaint that Mrs A had made that it had investigated. She said the Council had allowed the school in question to circumvent a proper and robust complaint process. She said this meant she did not get any answers about why her child had been harmed. The Ombudsman was concerned that whilst thematically there were similarities between the two complaints Mrs A had made, they were sufficiently distinct so that the Council’s conclusion that the complaints were substantially the same was unreasonable and not in accordance with the relevant Welsh Government guidance. As an early resolution of this complaint, and instead of undertaking an investigation, the Ombudsman sought and gained the Council’s agreement to ask the school, within 3 months, to reconsider its position with respect to Mrs A’s complaint of November 2023.

Cwynodd Mrs X fod Llywodraeth Cymru wedi methu ag ymateb i’w chwyn ynghylch cais ei mab am Arbenigwr Addysg Bellach, a gyflwynwyd ym mis Rhagfyr 2023. Daeth yr Ombwdsmon i’r casgliad nad oedd Llywodraeth Cymru wedi cofnodi cwyn Mrs X ac ymateb iddi yn unol â’i phroses gwyno. Dywedodd fod hyn wedi achosi ansicrwydd, rhwystredigaeth ac anhwylustod i Mrs X. Penderfynodd setlo’r gŵyn heb ymchwiliad. Fe wnaeth yr Ombwdsmon geisio a chael cytundeb Llywodraeth Cymru i ymddiheuro am yr oedi a’r anghyfleustra a achoswyd ac i gyhoeddi ei ymateb i’r gŵyn o fewn 4 wythnos.

Mr A complained about how Planning and Environment Decisions Wales (“PEDW”) handled his complaint, and that it had not responded to his emails. The Ombudsman found that there was an issue with PEDW not receiving some emails. She decided that PEDW was delayed in handling Mr A’s complaint, and that it had not thoroughly investigated the issues with Mr A’s emails. The Ombudsman said that this caused delays for Mr A and may have impacted his ability to appeal a case. She decided to settle the complaint without an investigation. The Ombudsman sought and gained PEDW’s agreement to apologise to Mr A and escalate his complaint in line with its complaints procedure, to consider how the complaint handling impacted the ability to appeal, to remedy any issues identified, and provide a final response within 20 working days.

Mr A complained that the Council failed to support his late father financially with his care home fees when his assets fell before the capital threshold set by Welsh Government. Mr A said the Welsh Government threshold was set at £50,000 and had been at that level throughout the duration of his attempt to secure funding for his father’s care home fees, to which Mr A believed he was entitled. Mr A was aggrieved that the Council had published incorrect and misleading information on its website, stating that the threshold was£30,000 (that threshold had been for 2017-2018). Mr A said that he was under the impression that his father was ineligible for financial assistance due to having £35,000 at the time (in 2022). He said it was only after he conducted further independent research that he was made aware of the inaccuracy of the Council’s guidance. The Ombudsman was of the view that the guidance in question had misled Mr A regarding the threshold which was applicable at the time and therefore significantly delayed his contact with the Council to request the necessary assessment of his father’s eligibility. Mr A’s father sadly died before the necessary assessment could be undertaken. As an Early Resolution of this complaint, and instead of undertaking a full investigation, the Ombudsman sought and gained the Council’s agreement to take the steps necessary to determine the financial assistance due, if any, to Mr A’s father based on the information available regarding his health/needs and financial assets during the period in question (i.e. from when his financial assets fell below the £50,000 threshold applicable at the time).The Council agreed to undertake this action within 3 months.

Mr R complained that Swansea Bay University Health Board had reset the referral to treatment time (“RTT”) clock for him to undergo a left hip arthroscopy after he was unable to attend an appointment. He said that this was the only appointment that he had been unable to attend, and that the reason for this was the short notice he was given. Mr R said that the decision to reset his RTT clock was unfair and not in line with Welsh Government guidelines. The Health Board agreed that there had been an error in resetting Mr R’s RTT clock. It agreed to correct the misapplied reset and to write to Mr R to apologise and explain the error and to clarify his true RTT clock time and estimated date for treatment. The complaint was settled on that basis.

Mr A and Mr B complained that Welsh Government had failed to use its powers to ensure that Conwy County Borough Council and Denbighshire County Council were taking action to meet the need for accommodation for Gypsies and Travellers as required by the Housing (Wales) Act 2014. Mr A and Mr B also complained that Welsh Government had failed to deal properly with a complaint they had made about this matter. Local authorities have a duty to meet the need for accommodation for Gypsies and Travellers. They are required to identify and assess the need in their area and submit a plan to Welsh Government for its approval. Welsh Government therefore has a critical leadership role in ensuring that local authorities carry out their duties for the provision of accommodation. The investigation found that Welsh Government had failed to carry out this role and that its failure to respond to Conwy &Denbighshire Councils had constrained the ability of Conwy and Denbighshire to meet the need for accommodation for Gypsies and Travellers. This has caused frustration and distress to both Mr A and Mr B, whose accommodation needs remain unmet. It is also likely that others in the community have been affected, or could be affected, by this failure. Mr A and Mr B’s complaint was not dealt with in accordance with Welsh Government policy. Their complaint was wrongly classified as one that could not be considered under the policy. The time taken to inform them that their complaint was not being considered was excessive. I recommended that the Welsh Government should apologise to Mr A and Mr B for the failings identified in this report and offer them a payment of £1,000 each in recognition of the injustice caused to them because of these failings. I also recommended that Welsh Government should inform local authorities of the requirement to continue to take steps to meet need in approved Gypsy and Traveller Accommodation Assessments whilst updated Gypsy and Traveller Accommodation Assessments ar

Mr A complained that the Health Board refused to warn patients referred to the Erectile Dysfunction Therapy clinic in advance that they would be expected to be examined and counselled by female clinicians. He said that the Health Board hid the fact that it would be a female clinician by sending appointment letters that just referred to a clinic, unlike other disciplines which would include the name (and hence gender), of the clinician they would be seeing. Mr A said the examination was hugely humiliating and embarrassing. Mr A said that Welsh Government guidelines stated that a patient may request to have such an examination by a person of the same gender, but it was impossible to make such a request without being forewarned. The assessment was concerned that patients should be properly informed of the gender of the clinicians with which they would be attending a potentially gender sensitive clinic. Instead of investigating this complaint, the Ombudsman sought and gained the Health Board’s agreement to undertake the following action to resolve the complaint: • The Health Board agreed to amend the template for Erectile Dysfunction Therapy clinic appointment letters so that they include the name of the clinician holding the clinic and information regarding the service being female-led and informing the patient that they can contact the Urology Department for assistance should that concern them. The Health Board agreed to undertake these changes within 1 month.

The Ombudsman received a referral that a member (“the Member”) of Vale of Glamorgan Council (“the Council”) had breached the Code of Conduct (“the Code”) when he applied for a number of business grants. The investigation considered whether the Member failed to comply with paragraphs 4(b), 4(d), 6(1)(a), 7(a), 7(b), 15(1)(b) and 15(2) of the Code. The investigation considered evidence from the Council and the Welsh Government Fraud Office.  Witnesses provided witness evidence.  The Member was interviewed. The investigation found that the Member sent emails from his Council email address about business grant applications he had submitted.  The Ombudsman found that the emails were not sent in the interests of Council business – they were sent for the benefit of the Member’s, and his wife’s, personal business interests.  The Ombudsman also found that, in sending emails as officers of the Council from his Council email address, the Member’s actions could be perceived as him attempting to use his position as an elected member to gain an advantage for himself.  The Ombudsman concluded that the Member’s actions were suggestive of a breach of paragraphs 6(1)(a), 7(a) and 7(b) of the Code. The investigation found that the Member failed to include 2 properties on his Register of Interests.  The Member had received training on the Code which included training on interests and registering and declaring any such interests.  The Member, alongside all other members of the Council, received consistent and regular reminders about the need to keep their Register of Interests updated.  In view of this, the Ombudsman considered that the Member’s failure to declare interests on his Register of Interests was suggestive of a breach of paragraphs 15(1)(b) and 15(2) of the Code. The investigation found that the Member failed to update the Council about the occupancy of 1 of his properties and was suggestive of a breach of paragraph 6(1)(a) of the Code.  However, the Ombudsman also noted that

Ms A complained about the service provided by the Student Loans Company in relation to her student funding. Specifically, she referred to her entitlement, as a part-time student, to a Special Support Grant, how an overpayment had been handled and childcare payments. Having made enquiries, the Ombudsman decided not to investigate the complaint, but asked SLC to undertake some further action instead to settle the complaint. The Ombudsman noted that Ms A had initially been incorrectly told that she was not entitled, as a part-time student, to receive a Special Support Grant. However, this was subsequently rectified and the grant awarded. On a more general level, there was a difference in the application forms for part-time and full-time students in relation to Special Support Grant information and there was no reason why this should be. The Ombudsman noted that Welsh Government and SLC had made arrangements to ensure that the forms were the same, but the changes required had not been put in place for the current academic year. This would happen in time for the 2024/25 academic year. In relation to the overpayment, the Ombudsman found evidence of maladministration due to a delay in properly explaining and rectifying the overpayment, despite this having been previously highlighted as part of the SLC complaints process. This delay had caused uncertainty for Ms A about the amount and how the overpayment was to be recovered. In recognition of this, SLC agreed to give a written apology to Ms A and to make an ex-gratia payment to her of £400. The Ombudsman found no evidence of maladministration in relation to the childcare payments.

Mr A complained that the Welsh Government failed to acknowledge or respond to his complaint that it had not acknowledged or responded to his previous correspondence. The Ombudsman decided that the Welsh Government’s decision not to acknowledge or respond to any of Mr A’s correspondence on a specific subject was unreasonable. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Welsh Government’s agreement to apologise to Mr A, provide a complaint response, acknowledge future correspondence, provide a rationale for any decision not to provide a response and inform Mr A of how any decisions to restrict correspondence will be reviewed. The Welsh Government agreed to complete the action within 10 working days.

Ms K complained about the treatment her late mother, Mrs L, received from Swansea Bay University Health Board (“the First Health Board”) and Hywel Dda University Health Board (“the Second Health Board”). In particular, she said that: The First Health Board • Failed to diagnose and treat Mrs L’s cancer in a timely manner and that the failure to operate sooner resulted in her premature death. • Failed to provide Mrs L and her family with an adequate level of information regarding her test results and treatment options. The Second Health Board • Failed to keep Mrs L informed as to the extent of her cancer and its clinical progression and provided conflicting information regarding surgery and treatment options. • Failed to provide Mrs L with appropriate medication and nutrition prior to her death. The Ombudsman’s investigation found the following: The First Health Board • Although the Welsh Government’s Suspected Cancer Pathway timeframe was missed, the First Health Board failed to take proactive action when a procedure could not take place due to a lack of anaesthetists. This delay meant there was a significant impact for Mrs L in that there was poor local tumour control which was the predominant cause of her cancer related symptoms. • There was a delay in Mrs L being given information about liver metastases as there were opportunities missed to communicate this information at an earlier stage. Both of these parts of the complaint were upheld. The Second Health Board • Although Mrs L received appropriate treatment and interventions, communication was poor with her family, national guidelines were not followed and there was confusion as to why certain decisions were made. In addition, a drug error was not reported to the family until after Mrs L’s death. This part of the complaint was upheld. • Mrs L was provided with appropriate medication and nutrition prior to her death. This part of the complaint was not upheld. The Ombudsman recommended that both health boards apol

Ms K complained about the treatment her late mother, Mrs L, received from Swansea Bay University Health Board (“the First Health Board”) and Hywel Dda University Health Board (“the Second Health Board”). In particular, she said that: The First Health Board • Failed to diagnose and treat Mrs L’s cancer in a timely manner and that the failure to operate sooner resulted in her premature death. • Failed to provide Mrs L and her family with an adequate level of information regarding her test results and treatment options. The Second Health Board • Failed to keep Mrs L informed as to the extent of her cancer and its clinical progression and provided conflicting information regarding surgery and treatment options. • Failed to provide Mrs L with appropriate medication and nutrition prior to her death. The Ombudsman’s investigation found the following: The First Health Board • Although the Welsh Government’s Suspected Cancer Pathway timeframe was missed, the First Health Board failed to take proactive action when a procedure could not take place due to a lack of anaesthetists. This delay meant there was a significant impact for Mrs L in that there was poor local tumour control which was the predominant cause of her cancer related symptoms. • There was a delay in Mrs L being given information about liver metastases as there were opportunities missed to communicate this information at an earlier stage. Both of these parts of the complaint were upheld. The Second Health Board • Although Mrs L received appropriate treatment and interventions, communication was poor with her family, national guidelines were not followed and there was confusion as to why certain decisions were made. In addition, a drug error was not reported to the family until after Mrs L’s death. This part of the complaint was upheld. • Mrs L was provided with appropriate medication and nutrition prior to her death. This part of the complaint was not upheld. The Ombudsman recommended that both health boards apol

Mr A complained about whether the Health Board appropriately considered his mother’s case as part of its nosocomial review process (a process set up by Welsh Government for Health Boards to review cases where a patient may have contracted Covid-19 in hospital) and in line with the National Framework and any other relevant policies/procedures. The investigation found that, although the review carried out by the Health Board into the care supplied to the complainant’s mother concluded it was reasonable, the explanation about how that decision had been reached was insufficiently detailed. The decision that there was no breach of duty and no qualifying liability was also not explained. The Health Board had reached a decision to revise the content of decision letters to improve the way it communicated key issues, in light of issues raised by the Ombudsman. However, given the timing of the complaint, this improvement did not impact the complainant’s case. The Ombudsman therefore reached an agreement with the Health Board for it to carry out afresh, thorough, nosocomial review, to include consideration of nosocomial, duty of care and qualifying liability issues. When that had been concluded, the Health Board agreed to write to the complainant to provide a fulsome explanation of the reasons for its decision within 6 weeks of the closure of the complaint.