PSOW Individual Decisions

Ms X complained that Aneurin Bevan University Health Board did not investigate her complaint. The Ombudsman decided that whilst the Health Board had provided a response, there were aspects of the complaint that were not addressed. She said that this caused delays and frustration. She decided to settle the complaint without investigation. The Ombudsman sought and gained the Health Board’s agreement within 10 working days, to apologise to Ms X, clarify her outstanding concerns and agree to provide a complaint response.

Mrs B complained that the Health Board failed to provide a complaint response to her in accordance with an agreement it had previously reached with the Ombudsman. Mrs B had originally made a complaint to the Health Board in July 2021. The agreement reached with the Ombudsman required the Health Board to issue the complaint response by 30 June 2022, which it did not do. The Ombudsman therefore contacted the Health Board and it agreed to complete the following actions by 31 August 2022: a) Issue a further apology to Mrs B for its failure to provide the complaint response as agreed. b) Offer a £250 time and trouble payment to Mrs B in recognition of the significant delay experienced in awaiting the Health Board’s response and Mrs B’s time in making further representations to this office. c) Issue the complaint response. The Ombudsman accepted the above as an alternative to issuing a Special Report.

Mrs X complained about the care her late husband, Mr X, received from Aneurin Bevan University Health Board (“the Health Board”). She said the care planning for Mr X and the treatment he received after February 2020 was not reasonable or timely, he was not prescribed and/or given medication appropriately when he was an in-patient between July 2020 and December 2020, and he was discharged from hospital inappropriately in December 2020. The Ombudsman’s investigation found that, following Mr X’s urgent cancer referral, he should have undergone a cystoscopy (an examination of the bladder using a thin tube with a light and camera on the end) under anaesthetic sooner than he did, and this likely resulted in Mr X’s bladder cancer taking longer to diagnose. This in turn meant that Mr X did not undergo chemotherapy sooner. Whilst it was not possible to be certain of the outcome, as a result Mr X did not undergo curative rather than palliative treatment. This was a service failure, and this uncertainty was an injustice to Mrs X and the Ombudsman upheld this part of the complaint. With regard to Mr X not being prescribed and/or given medication appropriately when he was an in-patient between July 2020 and December 2020, the Ombudsman found that before and after Mr X’s laparotomy (an incision into the abdominal cavity to examine abdominal organs) in July 2020 he was not fully assessed in relation to the risk of blood clots and deep vein thrombosis (DVT) (including being given injections of an anticoagulant) which he developed days later. This was a service failure and caused Mr X discomfort and a prolonged stay in hospital. The Ombudsman upheld this part of the complaint. The Ombudsman also had concerns about Mr X’s admission in December 2020 and the steps taken once again in relation to his assessment for blood clots. Whilst there were shortcomings, Mr X did not come to any harm, so the Ombudsman invited the Health Board to consider this admission as part of its reflection in

Mr A complained that Aneurin Bevan University Health Board failed to diagnose his daughter, B, with Attention Deficit Hyperactivity Disorder (“ADHD” – a condition that affects a person’s behaviour in terms of inattention and/or hyperactivity and impulsivity)in a timely manner as the 2 referrals that were made to the Integrated Service for Children with Additional Needs (“ISCAN”) in July 2019 and July 2020 were both incorrectly rejected. The Ombudsman found that the first referral in July 2019, which was made by B’s GP, contained limited information and supporting documentation. She concluded that, although B could have possibly been assessed after this referral, it was nevertheless within the range of a reasonable clinical decision that the referral was not accepted on this occasion. However, the Ombudsman found that the second referral in July 2020 should have been accepted, as ADHD features were clearer in the documentation and B met all the criteria from the referral checklist. After Mr A made a complaint to the Health Board, B was assessed by a Neurodevelopment Nurse and Child Psychiatrist, and a diagnosis of ADHD was subsequently reached. The Ombudsman concluded that there was a delay of at least 6 months in offering B an assessment and diagnosing her with ADHD and that it should not have taken Mr A having to make a formal complaint to obtain this diagnosis, and the support, that his daughter needed. This amounted to a significant injustice to Band her family due to the distress, but also the lack of support and treatment, that the rejection of the second referral caused. As a result, the Ombudsman upheld Mr A’s complaint. The Ombudsman recommended that the Health Board apologise to Mr A within 1 month of the final report. In light of the fact that there was a new process in place for processing and triaging neurodevelopmental referrals within the Health Board, the Ombudsman did not consider it relevant to make any specific recommendations in respect of neurode

Mr X complained that he had encountered a delay of 8 months in receiving a response, following a complaint to the Health Board. The Ombudsman was concerned that Mr X had yet to receive a response and contacted the Health Board. As an alternative to an investigation, the Health Board agreed that it would issue Mr X with a formal response by 1August 2022. The Ombudsman accepted this as a resolution to Mr X’s complaint.

Ms D complained about the care that she had received from Aneurin Bevan University Health Board. She said that one of the Health Board’s Community Mental Health Teams (“the CMHT”) had failed to assess her psychological condition properly, to diagnose her as having complex post-traumatic stress disorder (C-PTSD – a mental health condition that can be caused by exposure to horrific or distressing events that are repeated) and to prescribe appropriate treatment for her. The Ombudsman noted that the CMHT could have obtained more information about domestic abuse that Ms D had reported when it assessed her. She also observed that it would have been appropriate for the Consultant Psychiatrist involved to have recorded a comment about Ms D’s diagnosis during this assessment. However, she did not find that the CMHT had failed to assess Ms D’s psychological condition properly. She did not consider it possible to determine that Ms D had had C-PTSD when the CMHT assessed her. She found that the treatment prescribed for Ms D by the CMHT had been reasonable. She did not uphold Ms D’s complaint.

Mr X complained that the Practice failed toappropriately change his pain relief medication as instructed by the hospitaland failed to issue a repeat prescription. The Ombudsman found that whilst the Practice responded to Mr X’s concerns, it had done so verbally. It had not offered its response in writing in line with policy. The Practice therefore agreed to issue a full written complaint response by no later than 14 July 2022.

Ms A complained that the Aneurin Bevan University Health Board had failed to respond to a complaint, submitted to them on 6 July 2021. The Ombudsman found that the Health Board had failed to respond to Ms A’s complaint in accordance with The NHS (Concerns, Complaints and Redress Arrangements) (Wales) Regulations 2011 (“the Regulations”). The Ombudsman sought and gained the Health Board’s agreement to provide a written apology to Ms A and provide written confirmation that her complaint would be investigated in accordance with the Regulations, within 10 working days.

Mr A complained that there was an unacceptable 11 hour delay by the Welsh Ambulance Services NHS Trust (“WAST”) in an ambulance attending his late mother, Mrs M, on 3 and 4 November 2019. He also complained about WAST’s handling of his complaint. The Ombudsman’s predecessor decided to use his “own initiative” investigation power under Section 4 of the Public Services Ombudsman (Wales) Act 2019 to extend the existing investigation into WAST to include the actions of Aneurin Bevan University Health Board (“the Health Board”) in accordance with the Ombudsman’s criteria for commencing such an investigation. The Ombudsman extended the investigation to consider whether there was any maladministration or service failure on the part of the Health Board which contributed to the time Mrs M had to wait for an ambulance and to be seen in the Emergency Department (“ED”), once the ambulance arrived at the Royal Gwent Hospital (“the Hospital”). The Ombudsman’s investigation concluded that the calls to WAST were correctly categorised and appropriate searches were made to try to source an emergency ambulance to attend the calls. It was evident that delays transferring patients into the care of the Health Board seriously affected WAST’s ability to respond on this occasion. The Ombudsman was also satisfied that WAST’s complaint response was reasonable, and did not uphold Mr A’s complaint. The Ombudsman was satisfied that care provided to Mrs M on 3/4 November was broadly reasonable in the circumstances and the delay did not adversely affect Mrs M. However, she noted that the delays must have been distressing for both Mr A and his mother. Please Note: Summaries are prepared for all reports issued by the Ombudsman. This summary may be displayed on the Ombudsman’s website and may be included in publications issued by the Ombudsman and/or in other media. If you wish to discuss the use of this summary please contact the Ombudsman’s office. The Ombudsman was satisfied that the ED was under

Mr A complained that there was an unacceptable 11 hour delay by the Welsh Ambulance Services NHS Trust (“WAST”) in an ambulance attending his late mother, Mrs M, on 3 and 4 November 2019. He also complained about WAST’s handling of his complaint. The Ombudsman’s predecessor decided to use his “own initiative” investigation power under Section 4 of the Public Services Ombudsman (Wales) Act 2019 to extend the existing investigation into WAST to include the actions of Aneurin Bevan University Health Board (“the Health Board”) in accordance with the Ombudsman’s criteria for commencing such an investigation. The Ombudsman extended the investigation to consider whether there was any maladministration or service failure on the part of the Health Board which contributed to the time Mrs M had to wait for an ambulance and to be seen in the Emergency Department (“ED”), once the ambulance arrived at the Royal Gwent Hospital (“the Hospital”). The Ombudsman’s investigation concluded that the calls to WAST were correctly categorised and appropriate searches were made to try to source an emergency ambulance to attend the calls. It was evident that delays transferring patients into the care of the Health Board seriously affected WAST’s ability to respond on this occasion. The Ombudsman was also satisfied that WAST’s complaint response was reasonable, and did not uphold Mr A’s complaint. The Ombudsman was satisfied that care provided to Mrs M on 3/4 November was broadly reasonable in the circumstances and the delay did not adversely affect Mrs M. However, she noted that the delays must have been distressing for both Mr A and his mother. Please Note: Summaries are prepared for all reports issued by the Ombudsman. This summary may be displayed on the Ombudsman’s website and may be included in publications issued by the Ombudsman and/or in other media. If you wish to discuss the use of this summary please contact the Ombudsman’s office. The Ombudsman was satisfied that the ED was under

Mr X complained that despite a number of communications with the Health Board, he had not yet received an acknowledgement or response to his complaint. The Ombudsman was concerned that Mr X had not yet received a response from the Health Board and contacted the Health Board. As an alternative to an investigation, the Health Board agreed to provide Mr X with a formal response by 30 June 2022. The Ombudsman accepted this as a resolution of Mr X’s complaint.

Mrs A complained that the GP Practice (“the Practice”) failed to provide satisfactory care to her mother, Mrs B, and that this contributed to her rapid terminal decline in April 2020. Further, Mrs A said the Practice’s handling of her complaint was not adequate or robust. Mrs A also complained about the community nursing care provided the Health Board and about a telephone consultation with an Out of Hours GP (“the OOHGP”) on 15 April. Finally, Mrs A complained about the Oncologist at Velindre NHS Trust (“Trust”) and their communication with the family as well as the Trust’s complaints handling. The Ombudsman’s investigation found that, broadly, the consultations by the GPs were appropriate and that Mrs B’s rapid decline and death could not have been anticipated. However, given Mrs B’s sudden deterioration, a face-to-face consultation would have been helpful, especially as it later delayed the family getting a death certificate. Although this shortcoming did not contribute to Mrs B’s sudden deterioration, or alter the sad outcome, it added unnecessarily to the family’s distress at a difficult time. The complaint against the GP Practice was upheld to this limited extent. The Ombudsman also found shortcomings in the record keeping by the District Nurses’ that failed to provide adequate handover information for continuity of care. Records were also added retrospectively after Mrs A had complained. Although the investigation concluded that a home visit by the OOHGP was not necessary following the telephone consultation, given that there was every indication that Mrs B was likely to be close to death, this should have been discussed with Mrs A so that she was better prepared. The Ombudsman found that these communication failings caused an injustice to Mrs A and the family as it added to their distress at a very difficult time and this aspect of the complaint against the Health Board was upheld. Please Note: Summaries are prepared for all reports issued by the Ombudsman.

Mrs A complained that the GP Practice (“the Practice”) failed to provide satisfactory care to her mother, Mrs B, and that this contributed to her rapid terminal decline in April 2020. Further, Mrs A said the Practice’s handling of her complaint was not adequate or robust. Mrs A also complained about the community nursing care provided the Health Board and about a telephone consultation with an Out of Hours GP (“the OOHGP”) on 15 April. Finally, Mrs A complained about the Oncologist at Velindre NHS Trust (“Trust”) and their communication with the family as well as the Trust’s complaints handling. The Ombudsman’s investigation found that, broadly, the consultations by the GPs were appropriate and that Mrs B’s rapid decline and death could not have been anticipated. However, given Mrs B’s sudden deterioration, a face-to-face consultation would have been helpful, especially as it later delayed the family getting a death certificate. Although this shortcoming did not contribute to Mrs B’s sudden deterioration, or alter the sad outcome, it added unnecessarily to the family’s distress at a difficult time. The complaint against the GP Practice was upheld to this limited extent. The Ombudsman also found shortcomings in the record keeping by the District Nurses’ that failed to provide adequate handover information for continuity of care. Records were also added retrospectively after Mrs A had complained. Although the investigation concluded that a home visit by the OOHGP was not necessary following the telephone consultation, given that there was every indication that Mrs B was likely to be close to death, this should have been discussed with Mrs A so that she was better prepared. The Ombudsman found that these communication failings caused an injustice to Mrs A and the family as it added to their distress at a very difficult time and this aspect of the complaint against the Health Board was upheld. Please Note: Summaries are prepared for all reports issued by the Ombudsman.

Mx A was diagnosed with Nance Horan Syndrome (a rare genetic disorder), which causes a number of complications with communication including slurred speech as well as mobility issues. Mx A complained about the care and treatment they received in the Emergency Department (“the ED”) at Royal Gwent Hospital (“the Hospital”) in 2020. They felt that they were discriminated against because of their disability. They said that the Health Board failed to adequately address the ED nursing staff’s behaviour in May and July 2020 and the Lead Nurse for High Impact Service (“the Lead Nurse”) did not contact them as she said she would to devise a specific care plan should Mx A attend the ED again. Finally, Mx A complained about the robustness of the Health Board’s complaint handling. The Ombudsman was satisfied that broadly the medical/clinical care provided to Mx A was reasonable and appropriate. However, the Ombudsman identified areas where Mx A’s care could have been better and more effective than it was, for example, around pain assessment and management and the prompter introduction of a personalised care plan given that Mx A were a frequent attender to the ED. The Ombudsman’s investigation also found that some of the clinical entries in Mx A’s clinical records contained comments which were unhelpful and might have led to an adverse inference regarding the basis on which she was obtaining treatment. The Ombudsman was critical of the 9 months delay between the Lead Nurse’s initial contact and the completion of the care plan, especially given Mx A’s vulnerability and their continued anxiety when they needed to attend the ED. Administratively, the Ombudsman found shortcomings in the Health Board’s complaint response as it did not address issues around clinical documentation or the delays in creating a person-centred care plan and providing Mx A with a timely response. The Ombudsman found Mx A had been caused an injustice as a result of the failings and their complaints were uphel

Mrs A complained to Aneurin Bevan Health Board about its decision to discharge her father from hospital without thoroughly investigating his heart. Mrs A said that her father was home for 3-4 hours before being re-admitted to hospital via ambulance. Mrs A’s father sadly died following his second admission from a heart attack. The Ombudsman found that the Health Board had issued its complaint response to Mrs A, but she remained dissatisfied following its receipt. In resolution of her complaint, Mrs A was seeking a meeting with the Health Board to establish what went wrong. The Ombudsman sought and gained the Health Board’s agreement to contact Mrs A to arrange a meeting to discuss her complaint, within 20 working days.

Mr X complained about the treatment his late mother, Mrs Y, received at the Royal Gwent Hospital in September 2020 following a stroke, in particular the administration of medication to reduce her blood pressure. Mrs Y’s condition deteriorated; it was concluded that she had suffered a further “devastating event” within the brainstem and she sadly died a few days later. The Ombudsman found that Mrs Y had been given 3 different medications to reduce her blood pressure. Although one of them (a GTN infusion) was not indicated and should not have been given, and it would have been more appropriate to have delayed another medication until the following day, the deterioration in Mrs Y’s condition was not caused by a drop in her blood pressure and thus was not as a result of the medication she received. The Ombudsman also found there had been failings in record keeping. However, the service failure and administrative failings had not caused Mrs Y an injustice and, therefore, the Ombudsman did not uphold the complaint.

Mrs X complained that the Health Board had failed to respond to her complaint about the care and treatment provided to her husband, which she made to it on 23 July2021. In considering the complaint the Ombudsman was concerned that Mrs X had not received a response to her complaint and that it had been suggested by the Health Board that a meeting was held in lieu of a written response, contrary to the Putting Things Right (“PTR”)regulations. As an alternative to an investigation, she asked the Health Board to complete the following in settlement of Ms X’s complaint: By 30 June 2022 a) Apologise to Mrs X for the considerable delay in responding to her complaint b) Provide Mrs X with a written complaint response

Ms A complained that a Surgery failed to correctly address her transgender son on its calling board, disclosing his identity to other patients. Ms A also said the Surgery informed her son that he needed a new NHS number to change his gender on the system, and she was concerned how this would impact him being called for routine ‘female’ screening. Ms A was unhappy with the Surgery’s complaint handling. She also said that it did not respond to her emails and she had to contact the Local Health Board. A resolution meeting proved unsuccessful and Ms A’s family was removed from the Surgery’s patient list, without explanation or warning. The Ombudsman decided that the Surgery had mishandled how it addressed Ms A’s son, and the family’s subsequent complaints. She decided to settle the complaint without investigation. The Ombudsman sought and gained the Surgery’s agreement to apologise to Ms A for the complaint handling, and to provide a complaint response and rationale for the decision to remove the family from its patient list. It also agreed to review its current system for dealing with patient emails within one month.

Ms X complained about her discharge from hospital in May 2020, specifically that she was not fit to be discharged and that it was not appropriate to move her to [Y] Care Home. Ms X was re-admitted to hospital just a day after her discharge. The Ombudsman found that Ms X was not fit for discharge – she was in great pain, was frail and her mobility and her ability to carry out activities of daily living were limited; she was also having dialysis 3 times per week. The Health Board had given Ms X only 2 options – to move to the Care Home, despite her expressed wish not to do so, or to go home with an inadequate package of care. The Ombudsman found that the Health Board did not satisfy itself that the Care Home could meet Ms X’s needs; it was not appropriate to discharge her to a care home which could not meet her needs and against her wishes. She upheld the complaint. The Ombudsman recommended that the Health Board apologise to Ms X for the failings identified and offer her a redress payment of £500 in recognition of the distress caused. She also recommended the Health Board take action to remind staff of the importance of carrying out discharge assessments, involving patients in discharge decisions and ensuring the discharge destination is suitable. The Health Board agreed to implement the recommendations.

Ms B complained about her late mother, Mrs C’s, treatment in 2 hospitals within the Health Board’s area. She queried whether the Health Board: • Should have done more to assist in obtaining new dentures for Mrs C after they went missing during her admission? • If the insertion of a feeding tube was necessary, as a direct consequence of Mrs C missing her bottom dentures? • If the feeding tube should have been re-inserted after it became dislodged during transfer to the Second hospital? • If a failure to administer blood thinning medication as prescribed, resulted in clinical harm to Mrs C? • If Mrs C understood the implications of agreeing to no further needles and tubes on the day before her death, given her clinical situation? • If she had been given an appropriate update on Mrs C’s clinical condition on the morning of her death, and should have been contacted to sit with Mrs C before she died? The Ombudsman found that whilst staff were aware of the missing dentures, and made several entries in Mrs C’s medical notes about the need to replace them, no action was taken to progress this. The Ombudsman also found that Ms B did not appear to have received a full update on the date of her mother’s death informing her of the severity of her condition. Although COVID-19 restrictions limited visitor access, the Ombudsman found that it should have been apparent that Mrs C was nearing the end of her life, and therefore Ms B should have been given the option to visit her. These were injustices to Mrs C and her family, and these elements of the complaint were therefore upheld. The investigation found that Mrs C was offered a variety of food and drink, that could be consumed without dentures, but Mrs C either refused or only took small amount of these, so although the missing dentures were one reason for the feeding tube, it could not be proved that it was the only or main reason the tube was needed. The investigation found that multiple attempts were made to re-insert the tube,

Mr Y complained about the care his wife, Mrs Y, received following admission to hospital in January 2019 with a severe headache. Following a clear head scan, a decision was made to carry out an Epidural Blood Patch (“EBP”, a procedure commonly used to treat spinal headaches). 2 days later, Mrs Y’s condition deteriorated suddenly and investigations identified a brain haemorrhage; despite undergoing surgery, Mrs Y sadly died. The Ombudsman concluded that: • Mrs Y was appropriately assessed on admission and a diagnosis of Intracranial Hypotension (where there is an abnormally low pressure within the skull resulting in a headache) was within the bounds of acceptable clinical practice based on Mrs Y’s presenting symptoms and previous history of similar headaches. • The consent for the EBP and the procedure itself was carried out within the bounds of acceptable clinical practice and in line with relevant guidelines; the haemorrhage Mrs Y was subsequently diagnosed with was not a recognised complication from an EBP procedure. • Whilst it was unclear how long Mrs Y was lying down after the procedure as her positioning was not documented, even if she had been laying down for less than the recommended time, this would not have been a contributory factor to the haemorrhage she subsequently developed. • There was no reason to request a medical review following the EBP as Mrs Y was noted to be reasonably comfortable the following day and Mrs Y received regular nursing reviews. The Ombudsman did not uphold Mr Y’s complaints relating to Mrs Y’s clinical care. However the Ombudsman found that the time taken by the Health Board to conclude its investigation into Mr Y’s complaint, and the use of medical terminology without clear explanations/suitable definitions within the investigation report amounted to maladministration and fell outside the requirements laid out in its policy for managing serious concerns (“the policy”). This was an injustice to Mr Y and this complaint was upheld.

Ms A complained on behalf of her daughter, B, about the appropriateness of mental health assessments carried out by the Children and Adolescent Community Mental Health Service (“CAMHS”) during her admission to the Royal Gwent Hospital (“the Hospital”) in May 2020 after she swallowed some button batteries. B reacted badly to being told that she was going to be discharged back to her residential placement, and in separate incidents, she ran out of the Hospital in front of traffic and then jumped off a 20ft wall and was injured. Ms A said that more should have been done to keep B safe during her admission and she questioned the appropriateness of ongoing plans to return B to the placement in view of the escalation in her behaviour. The Ombudsman found that the assessments of B were conducted to an appropriate standard. The decisions taken were evidence-based on the information available at the time and fell within the range of acceptable clinical practice in the given circumstances. Appropriate mitigation in view of B’s risk-taking behaviour was put in place in the Hospital and was also planned for her return to the placement. Sadly, B’s extreme reaction to the decision that she should return to the residential placement could not have been anticipated by the Medical Team overseeing her mental health care while she was in the Hospital. Accordingly, the plan for B changed in view of the escalation in her behaviours and an alternative plan for inpatient care was implemented. In the absence of any evidence of significant service failure, the Ombudsman did not uphold the complaint.

Miss X complained that the Surgery changed the frequency of her prescriptions from monthly to fortnightly without explanation. The Ombudsman decided that the Surgery should provide Miss X with a “Putting Things Right” (the formal NHS complaints process in Wales) compliant written response (within 3 weeks) which should explain the reasons why there was a change in the frequency of her medication. The Ombudsman considered this to be an appropriate resolution to the complaint instead of conducting an investigation.

Ms X complained that the Health Board had not responded to the complaint she had submitted in November 2019 about her sister’s treatment in hospital. Shortly after the complaint was submitted to the Ombudsman, the Health Board did finally respond to Ms X, with its written response including an offer of financial redress in respect of the acknowledged failings in care. However, the Ombudsman found that the handling of the complaint had been inadequate in terms of timeliness and communication with the complainant about the delay in responding. The Ombudsman asked the Health Board to provide Ms X with a written apology for its poor complaint handling, together with a payment of £250 in recognition of the avoidable time and trouble to which she had been put. The Health Board agreed to do so within 10 working days. The Ombudsman considered this a suitable settlement and did not investigate.

Mr L complained about the care provided to his late mother, Mrs M, when she was an inpatient in November 2019. Specifically, Mr L complained that the Health Board failed to monitor and treat Mrs M’s breathlessness properly; failed to provide her with adequate support to use the toilet; did not give enough consideration to meeting Mrs M’s religious and cultural needs; did not communicate effectively with Mrs M or her family about her care and did not take appropriate action to prepare Mrs M’s body following her death. Although it could not be said with certainty that the outcome would have been different, the Ombudsman found that there were failings in the monitoring and treatment of Mrs M’s breathlessness. In particular, the investigation identified inadequate nursing monitoring, an amendment to the plan of care which was not supported by a chest X-ray and that a CT scan had not been carried out as planned for reasons which were unclear. The Ombudsman also found that the care plan for Mrs M’s toileting needs was inadequate and that there was a failure to meet her cultural or religious needs, for example, by failing to offer her the Halal menu. The Ombudsman also upheld the complaints about communication with Mrs M and her family; in particular, that insufficient assessment had been made of Mrs M’s communication needs when she had limited understanding of English. It was not enough to rely on family members who happened to be present to translate for her without an assessment of whether this was sufficient or appropriate. Finally, the Ombudsman partly upheld the complaint about the preparation of Mrs M’s body to the extent that a cannula was not removed. The Ombudsman recommended that the Health Board should apologise to Mr L for the failings identified and pay financial redress of £5,000 in recognition of the impact these had on Mrs M and her family. He also recommended that relevant staff be reminded of the importance of regular monitoring, effective communication