PSOW Individual Decisions

Mr A complained about the way in which his complaint, regarding the standard of care his son had received from the Council’s Children’s Social Services department, had been handled by the Council. Specifically, that his Social Services complaint had not been escalated to Stage 2 and that there had been delays in complaint updates. The Ombudsman found that, although the Council had acknowledged and considered Mr A’s complaint at Stage 1, it failed to escalate to Stage 2. Furthermore, the Council delayed in updating Mr A following a complaints meeting, which Mr A said had caused inconvenience and uncertainty. The Ombudsman decided to settle the complaint without investigation. The Ombudsman sought and gained the Council’s agreement to, within 2 months of issuing the decision letter, write to Mr A to apologise for the delays in updates and for not escalating his complaint to Stage 2. It also agreed to instigate the Stage 2 complaints investigation and appoint an Independent Investigator.

Complaint that the HB failed to address her concerns about a failure to arrange a Multidisciplinary Team (MDT) review. Complainant thought her case was being referred for MDT review in August 2024.

Mr A complained that Hywel Dda University Health Board failed to respond to the complaint he submitted regarding an appointment he was not made aware of. The Ombudsman found that, while the Health Board had responded as an enquiry, it could have provided more information to Mr A. The Ombudsman said this caused uncertainty and frustration for Mr A and decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to, within 4 weeks, provide a full complaint response, apologise for the delay and for not including all the information and explain why this happened.

Ms F complained about the care her partner, Mr E, received from Swansea Bay University Health Board (“the Health Board”). The Ombudsman investigated whether appropriate examination and investigations were undertaken of Mr E’s symptoms when he presented at the Out-of-Hours (“OOH”) GP service on 13 April 2025. The investigation found that the assessment of Mr E’s condition and the resulting plan of care was appropriate in the circumstances. The OOH GP who reviewed Mr E, gathered relevant information and formed a clinically appropriate management plan for him to continue with pain relief, as required, and to see his own GP for follow-up. The Ombudsman did not uphold the complaint.

Mrs A complained that the Health Board did not take seriously and/or properly progress referrals from her GP, regarding a facial lesion which was diagnosed as being cancerous in May 2024. The investigation focused specifically on whether the Health Board’s assessment of Mrs A’s facial lesion and the GP referrals between August 2020 and September 2023 were clinically appropriate. The investigation found that the initial management of Mrs A’s lesion in 2020/21 and discharge from the Dermatology service was clinically appropriate. The investigation also found that, whilst the images shared by Mrs A’s GP with the Dermatology service in September 2023 did not indicate the classical features of nodular basal cell carcinoma (“BCC” – the most common type of skin cancer), they were clinically suggestive of a less common type of BCC which required further assessment. On this basis, following the GP referrals, either a request for additional images with a dermoscope (examination of skin conditions using a dermoscope – a specialised device that magnifies the skin surface) or a face-to-face appointment should have taken place. Rejecting the referrals without any further assessment represented a service failure. As BCC is a slow growing tumour, it is unlikely to have spread much during the investigation timeframe. Therefore, earlier assessment would not necessarily have altered the treatment Mrs A received or the outcome of that treatment, although there remains a possibility that it may have. This left Mrs A with the uncertainty that earlier review and investigations might have made some difference. The complaint was upheld to this extent. The Health Board agreed to apologise to Mrs A for the identified failings, to share the report for learning with the relevant clinicians and to review Mrs A’s images at a Dermatology service meeting to identify learning.

Mrs A complained about the Health Board’s management of her father, Mr C’s, pancreatitis (an inflammatory condition of the pancreas) and subsequent diagnosis of pancreatic cancer. The investigation focused only on whether Mr C received appropriate medical management and intervention between January 2023 and January 2024, relating to his pancreatitis; whether Mr C’s pancreatic cancer should have been investigated and diagnosed earlier; whether appropriate treatment was provided to Mr C following his diagnosis of pancreatic cancer; and, whether an appropriate palliative care plan was put in place, and implemented for Mr C. The investigation found that Mr C’s management before and after his cancer diagnosis was clinically appropriate and there were no missed opportunities to diagnose pancreatic cancer sooner. Whilst Mr C’s presentation included symptoms which were similar to pancreatic cancer, appropriate and extensive investigations did not identify cancer during 2023, with the possibility of pancreatic cancer identified only in early 2024. However, there were shortcomings in the level of service Mr C received from the dietetics service due to limited documentation to evidence appropriate actions. In addition, there were also communication shortcomings due to a disconnect in communication which meant a lack of clarity for the family about Mr C’s management. Complaints a) and b) were upheld to this limited extent. The investigation found when Mr C received a formal diagnosis of cancer, it was metastatic and incurable and therefore the recommendation for palliative chemotherapy was the correct management plan. In terms of dietetic service involvement, the community dietetic team made an appropriate referral/handover to the hospital dietetic service in February 2024 due to Mr C’s hospital admission. According to acute nutrition support standards, the earliest the hospital dietetic team would have seen Mr C was the day before he died. However, had they seen him as planned

Mrs A complained that Trivallis failed to respond to the complaint she submitted regarding the works that need completing at the property. The Ombudsman found that the Housing Association failed to provide a complaint response. The Ombudsman said this caused uncertainty and frustration for Mrs A and decided to settle the complaint without an investigation. The Ombudsman sought and gained the Housing Association’s agreement to, within 3 weeks, provide a final complaint response that will also include an apology and explanation for the delay.

Mrs A complained on behalf of her mother, Ms B, about noise and vibration she was experiencing in her Wales & West Housing Association flat. The Ombudsman found that when Ms B complained to the Housing Association about the noise and vibration it was not logged and a specific complaint response was not provided as per its procedure. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Housing Association’s agreement to apologise to Ms B and to issue a complaint response within 4 weeks of the Ombudsman’s decision.

Miss A complained that Cadwyn Housing Association failed to respond to her complaint about water ingress to a shared chimney stack. The Ombudsman found that the Association had not responded to Miss A’s complaint. She said this caused uncertainty and frustration to Miss A. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Association’s agreement to, within 3 weeks, offer Miss A an apology and explanation for the delay and to issue its response

Mrs A complained about the outcome of two foot surgeries in March and June 2023, and the overall management of her care by Aneurin Bevan University Health Board. The Ombudsman recognised that there was a significant delay in the Health Board providing its response to Mrs A and that it failed to keep her appropriately updated. Mrs A had outstanding concerns that had not been addressed, including her belief that another patient’s records were placed on her file. The Ombudsman also noted a number of mistakes within the response. The Ombudsman sought and gained the Health Board’s agreement to, within 4 weeks, offer a payment of £250 to Mrs A for the complaints handling delays, apologise for the errors identified and place a note on the complaints file to correct these, and contact Mrs A to discuss her concern regarding her records. Then within 8 weeks, to investigate and provide a further response to Mrs A on the outstanding issues.

Mr A complained that Betsi Cadwaladr University Health Board failed to address his concerns in its response. The Ombudsman found that the Health Board had failed to respond to the questions raised by Mr A. She said this caused uncertainty and frustration for Mr A. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to, within 4 weeks, issue a further response and offer an apology for failing to address Mr A’s concerns.

Mr A complained about the actions of Caerphilly County Borough Council in the exercise of its social services functions. The Council investigated Mr A’s concerns under its corporate complaints policy. The Ombudsman decided that the Council should have investigated Mr A’s complaint in line with The Social Services Complaints Procedure (Wales) Regulations 2014 and the Council’s own policies. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Council’s agreement to, within 2 weeks, contact Mr A to apologise that it did not correctly investigate his concerns in the first instance, and agree to reconsider the concerns he raised in his submission.

Ms C complained that Monmouthshire County Council declined to investigate her complaint about a care home’s decision to prevent her from visiting her mother, in what transpired to be the final days of her mother’s life. The Ombudsman decided that because the Council funded the placement it should have responded to Ms C’s complaint, and considered the rights of both Ms C and her late mother. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Council’s agreement to offer Ms C an apology and acknowledge her complaint within 1 week, and to provide a formal response in line with its complaints procedure.

Ms A complained that Aneurin Bevan University Health Board failed to respond to a complaint submitted in July 2025. The Ombudsman found there had been a significant delay with the Health Board responding to Ms A’s complaint and that it failed to keep her regularly updated. This caused additional frustration and uncertainty for Ms A. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to write to Ms A, within 1 week, to apologise for the delay. It also agreed to issue its complaint response within 4 weeks, or issue an update letter if the complaint investigation is not completed.

Mr A complained that Hywel Dda University Health Board failed to respond to the complaint he submitted in July 2025. The Ombudsman found that the Health Board failed to provide Mr A with a final complaint response. The Ombudsman said this caused uncertainty and frustration for Mr A and decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to, within 6 weeks, provide a final complaint response, apologise for the delay and explain why this happened, and offer a £100 financial redress payment in recognition of the delays.

Mrs L complained about the care provided to her late brother, Mr M. We investigated concerns about whether opportunities were missed to make an earlier diagnosis of pulmonary embolism (a blocked blood vessel in the lungs) and whether Mr M’s treatment after diagnosis of a pulmonary embolism was appropriate, timely and in keeping with relevant guidance. The investigation found that despite Mr M’s presentation giving reason to consider a diagnosis of pulmonary embolism, relevant tests were not conducted. This was a failing and an injustice to Mrs L who will be left with uncertainty regarding what the outcome may have been had these tests been conducted. This part of Mrs L’s complaint was upheld. Once pulmonary embolism was diagnosed, Mr M’s clinical management was appropriate and treatment was carefully considered and risk assessed in light of his complex condition. This part of Mrs L’s complaint was not upheld. The Health Board agreed to apologise to Mrs L and offer her financial redress of £750 in recognition of the distress caused by the uncertainty she will be left with. It also agreed to ensure that the clinicians that treated Mr M during his first admission to the Hospital are familiar with the symptoms of pulmonary embolism, particularly in patients with pre-existing lung conditions.

Miss A complained about the care and treatment that she received during her inpatient admission at Royal Gwent Hospital (“the Hospital”). The investigation considered whether it was clinically appropriate for the prescribed cyclizine (an antihistamine and antiemetic drug for management of nausea) to be changed from intravenous to oral administration, for the prescribed dosage to be decreased and whether these aspects of the treatment plan were communicated appropriately to Miss A. It also considered if Miss A was afforded appropriate support from mental health services during the extended time that she was an inpatient, in particular, after she took an overdose on 23 January 2024. Finally, the investigation considered whether the Health Board appropriately reported on, recorded and investigated the overdose at the time of the incident. The investigation found that the prescribed dosage of cyclizine was consistent and the dosage and mode of administration were both in keeping with standard practice. Miss A was kept informed of the management plan but there was a missed opportunity to ascertain why she was intent on being prescribed the medication via IV; however, this did not amount to a service failure. There was no evidence within the clinical records that Miss A had requested psychiatric input, rather, it was recorded that support was appropriately offered at various points during admission, but declined by Miss A who had capacity to make that decision. The clinical actions taken in response to Miss A’s overdose were appropriate; however, the incident was not reported in line with expected process. The Health Board has, during the course of this investigation, retrospectively recorded the incident. I am satisfied that Miss A did not suffer an injustice as a result of this omission as she received appropriate care regardless of the failure to document the incident. Nevertheless, the Health Board has been invited to remind all staff within the Urology and Medical te

Ms A complained that Cardiff Council failed to repair her leaking guttering since the Summer of 2024. The Ombudsman found there had been a significant delay with the Council attending to repairs to Ms A’s guttering which caused additional frustration and uncertainty for Ms A. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Council’s agreement to write to Ms A, within one week, with its apology and an offer of £100 for the time and trouble. It also agreed to renew the guttering within six weeks

We investigated Mrs A’s complaint about whether the Council adhered to the appropriate guidelines, regulations and associated code of practice in relation to 2 carers assessments and the decision made by the Council to decline overnight respite as recommended in both assessments. The investigation found that the carers’ assessment lacked the key elements as required under the relevant code. Whilst the second assessment identified the emotional and physical impact on Mrs A due to her caring role, and that she had not been receiving adequate breaks, the assessment did not sufficiently integrate detailed analysis of her son, B’s, behavioural needs, sleep patterns, and level of dependency into a clear, outcome-focused rationale for overnight respite provision. This likely impacted on the decision to decline overnight respite. These shortcomings in the assessment process amounted to service failure which caused Mrs A and injustice. This complaint was upheld. Whilst the panel decision to decline overnight respite based on the information contained in the assessment was likely to have been appropriate, some of the actions it proposed could have been facilitated sooner. This was a shortcoming which likely delayed the decision-making process. The complaint was upheld to this limited extent.

Mr C complained on behalf of his late mother, Mrs A, about the care and treatment she received from her GP Practice. The investigation considered whether the management of Mrs A’s back pain from February to July 2023 was clinically appropriate. Mr C also complained about the care and treatment Mrs A received from the Health Board. However, the Health Board chose not to investigate this complaint. The Ombudsman used her discretion to investigate the matter without the Health Board having provided a response. The investigation considered whether Mrs A’s care and treatment during her first admission on 31 March 2023 was clinically appropriate and whether there should have been a follow-up. The investigation also considered whether the management of referrals from Mrs A’s GP by the Health Board was appropriate between February 2023 and her second admission on 17 July 2023. The investigation found that the management of Mrs A’s back pain by the Practice did not reach an appropriate standard, as red flags that might have indicated Mrs A’s cancer were not identified. The Ombudsman upheld this complaint point. It also found that the care and treatment provided to Mrs A during her admission on 31 March was not clinically appropriate because she was not examined by the correct specialism and clinicians failed to consider an alternative diagnosis for her pain. The Ombudsman also upheld this complaint point. Finally, the investigation found that the Health Board’s management of referrals from Mrs A’s GP was appropriate and so this point was not upheld. The Practice accepted the Ombudsman’s recommendations and agreed to apologise to Mr C and his family, and provide a copy of the Red Flags Guidance to all its clinicians. The Health Board accepted the Ombudsman’s recommendations and agreed to apologise to Mr C and his family, to review the case for points of learning, to remind relevant clinical staff of guidance around intimate examinations, and to make improvements to its record

The Ombudsman investigated Mr A’s complaint about whether the Health Board appropriately managed his position on the waiting list for gallbladder removal surgery. The investigation found that, despite a decision being made to place Mr A on the waiting list for a laparoscopic cholecystectomy (a surgical procedure to remove the bladder) in February 2023, due to an error, this did not happen. This error was only identified in March 2024, when Mr A contacted the Health Board for an update on his treatment pathway. The investigation identified that this failure amounted to maladministration. That said, when considering what injustice this caused, the investigation found that it was unlikely that Mr A would have received an appointment for surgery and/or undergone the surgery before the error was corrected given the subsequent delay for surgery. The investigation also found that, when the error was identified, the Health Board corrected this promptly and placed Mr A on the waiting list at the position he would have been had the error not occurred. The Health Board took appropriate corrective action in addressing the error and therefore did not act with maladministration. The investigation found that communication with Mr A about his position on the waiting list amounted to maladministration. This is because the explanations provided appeared confusing and lacked sufficient clarity about why his position had changed on the waiting list, but his prioritisation had not. This was an injustice to Mr A. The complaint was upheld to this limited extent in relation to communication. The Health Board agreed to provide Mr A with an apology for the failures outlined.

Mr C complained on behalf of his late mother, Mrs A, about the care and treatment she received from her GP Practice. The investigation considered whether the management of Mrs A’s back pain from February to July 2023 was clinically appropriate. Mr C also complained about the care and treatment Mrs A received from the Health Board. However, the Health Board chose not to investigate this complaint. The Ombudsman used her discretion to investigate the matter without the Health Board having provided a response. The investigation considered whether Mrs A’s care and treatment during her first admission on 31 March 2023 was clinically appropriate and whether there should have been a follow-up. The investigation also considered whether the management of referrals from Mrs A’s GP by the Health Board was appropriate between February 2023 and her second admission on 17 July 2023. The investigation found that the management of Mrs A’s back pain by the Practice did not reach an appropriate standard, as red flags that might have indicated Mrs A’s cancer were not identified. The Ombudsman upheld this complaint point. It also found that the care and treatment provided to Mrs A during her admission on 31 March was not clinically appropriate because she was not examined by the correct specialism and clinicians failed to consider an alternative diagnosis for her pain. The Ombudsman also upheld this complaint point. Finally, the investigation found that the Health Board’s management of referrals from Mrs A’s GP was appropriate and so this point was not upheld. The Practice accepted the Ombudsman’s recommendations and agreed to apologise to Mr C and his family, and provide a copy of the Red Flags Guidance to all its clinicians. The Health Board accepted the Ombudsman’s recommendations and agreed to apologise to Mr C and his family, to review the case for points of learning, to remind relevant clinical staff of guidance around intimate examinations, and to make improvements to its record

Mr C complained that Denbighshire County Council failed to issue a response to his complaint, which he made in September 2025, regarding refuse collection. The Ombudsman found that the Council failed to issue a complaint response. She said this caused frustration and uncertainty to Mr C. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Council’s agreement to apologise and provide an explanation to Mr C for the delay, as well as issue the complaint response within 4 weeks.

Ms D complained about the standard of care provided to her late mother, Mrs E, by the GP Practice. Ms D complained that, following a home visit in April 2025, the GP did not arrange Mrs E’s admission to hospital. The Ombudsman’s investigation considered the clinical assessment of Mrs E at the home visit, and the action taken as a result of that assessment, including the decision not to arrange Mrs E’s admission to hospital. The Ombudsman found that the clinical assessment of Mrs E during the home visit was appropriate. However, the recording of the clinical findings should have been more detailed. This aspect of the complaint was therefore partly upheld, limited to the associated record keeping. The Ombudsman concluded that the decision not to arrange emergency admission to hospital for Mrs E was not unreasonable or outside of accepted clinical practice. This aspect of the complaint was not upheld.

Ms L complained that the Health Board failed to take timely and appropriate action to investigate her persistent diarrhoea and rectal bleeding in 2021, and then to identify and diagnose her colon cancer following her GP’s urgent referral in February 2023. The investigation found that, whilst a colonoscopy in 2021 did not identify any disease in Ms L’s bowel, there is a recognised “miss rate” which means that disease can be missed through no fault of the procedure or the clinician conducting it. Ms L’s cancer had probably developed from a polyp that was missed in the original 2021 colonoscopy. There were failures to consider this possibility and repeat that procedure, as well as a lack of appropriate proactive investigation to find the cause of Ms L’s ongoing symptoms. There were also lengthy delays confirming test results and arranging follow-up appointments. These failings and delays meant that the opportunity to remove this polyp, and therefore either prevent Ms L’s cancer from developing or identify it when it was easier to treat, was lost. Ms L’s treatment included 2 life changing surgeries, chemotherapy and radiotherapy, and the whole situation had a serious impact on her physically, mentally and financially. This was a significant injustice to Ms L. Accordingly, the complaint was upheld. The Health Board agreed to apologise to Ms L for the failings identified and offered her £4,000 in recognition of the serious consequences. It also agreed to remind relevant clinicians of the recognised “miss rate” in colonoscopies and the importance of fully investigating ongoing symptoms even if a colonoscopy is clear. The Health Board also agreed to review the waiting list for surveillance colonoscopies to identify any patients waiting with an urgent clinical need and to offer them an appointment. Finally, it agreed to confirm that the relevant doctor in this case reflected on the findings of the Ombudsman’s report at his next annual appraisal.