PSOW Individual Decisions

Miss A complained about the care and treatment afforded to her father, Mr C, by Cardiff and Vale University Health Board (“the Health Board”) prior to his death in 2022. The circumstances of his death were subject to a Coroner’s Inquest, and Miss A had received a formal response from the Health Board prior to its conclusion. The Ombudsman contacted the Health Board. It explained that it had received a complaint from Miss A on 6 October 2025. It suggested that it respond to the concerns which Miss A raised. The Ombudsman found this to be a reasonable proposal. The Ombudsman sought and gained the Health Board’s agreement, within 6 weeks, to provide Miss A with a formal “Putting Things Right” response to the concerns she raised in her recent email.

Mr A complained about the communication provided by the Health Board about access to dental care and treatment. The Ombudsman found that, although the Health Board had provided information to Mr A, this did not comprehensively detail the options available to him for dental care and treatment and any support available to access this. The Ombudsman contacted the Health Board, which agreed to undertake the following actions to resolve the complaint and as an alternative to a formal investigation. The Ombudsman sought and gained the Health Board’s agreement to provide Mr A with information to clarify the current options available to him for dental care, including emergency treatment, and any support available to access this. The Health Board agreed to do this within 2 weeks.

Miss G complained that Cardiff and Vale University Health Board failed to address one aspect of her complaint, relating to issues with contacting it, made in June 2025. The Ombudsman found that the Health Board failed to address this aspect of her complaint. This caused additional frustration and uncertainty for Miss G. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to, within 2 weeks, write to Miss G to apologise for failing to address this aspect and to provide contact information for a person she can speak to.

Mr D complained that a GP Practice in the area of Cardiff and Vale University Health Board failed to respond to a complaint he raised in July 2024. The Ombudsman found that the Practice failed issue a formal complaint response until the intervention of her office in August 2025. This caused additional frustration and uncertainty for Mr D. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Practice’s agreement to, within 2 weeks, write to Mr D to apologise for the delay and offer a £150 redress payment.

We commenced an investigation of Mr B’s complaint against a GP Practice in the area of Cardiff and Vale University Health Board (“the Surgery”) to determine whether the Surgery: • Delayed processing information it received from Mr B’s son (Mr C) about a Shared Care Agreement (“SCA”) which delayed his referral to the Community Mental Health Team (“the CMHT”). • Was able to demonstrate it properly considered Mr B’s request for reimbursement of costs for privately funded medication for the period of delay. In response to the investigation, the Surgery accepted shortcomings in the handling of information provided by Mr C about the SCA. It recognised this delayed Mr C’s referral to the CMHT and resulted in him paying for private medication longer than he would have, had the information been processed sooner. The Surgery agreed to a proposal to address Mr B’s concerns. The Ombudsman determined that the actions it had agreed to take were proportionate to reach a voluntary settlement of Mr B’s complaint and would deliver an appropriate outcome. On this basis, the investigation was closed. The Surgery agreed to: • Provide a written apology for the administrative failings identified in processing paperwork which caused a delay in a CMHT referral. • Re-consider reimbursement of costs incurred for privately funded medication during the period of delay in Mr C being referred to the CMHT and confirm the outcome of the review with Mr B.

Mr A complained that the Cardiff and Vale University Health Board failed to send referral letters to his new GP so that he could continue his treatment outside of Wales. The Ombudsman found that the Health Board issued a referral letter to Mr A’s new GP in March 2025 but could not confirm if the letter had been received. This caused additional frustration and uncertainty for Mr A. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Boards agreement to, within one week, re-issue the referral letter by email or recorded delivery.

Mrs X complained about the care and treatment her late father received at Cardiff and Vale University Health Board. The Ombudsman found that the Health Board had identified a qualifying liability, however, it had failed to advise Mrs X of her right to legal advice under the financial redress provision of the ‘Putting Things Right’ procedure, which the Ombudsman said was a disadvantage to Mrs X. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to, within 1 week, write to Mrs X clearly outlining the next steps in the process and informing her of her right to legal advice.

Mr C complained about the care and treatment he received from the Health Board. The investigation considered whether the routine fitting of a catheter for Mr C, performed by the District Nurse Service on 25 September 2023, was carried out appropriately, and whether this could have resulted in Mr C’s need to be hospitalised and treated for infection. The Ombudsman found that the catheterisation of Mr C was not carried out appropriately, and was not in line with clinical standards. In addition, the Health Board’s explanation about what happened did not align with how events were recorded in Mr C’s clinical records. The investigation found that, on the balance of probability, these failings introduced an increased infection risk which was likely to have resulted in Mr C’s hospitalisation and infection. This was an injustice to Mr C. The Ombudsman upheld this complaint. The Health Board agreed to provide a written apology to Mr C for the failings identified in the report and to share the report with the District Nurse involved in Mr C’s catheterisation, to consider and reflect upon the findings. The Health Board also agreed to introduce an audit/review process, if not already in place, to monitor staff compliance/completion against expected training requirements, and to share the investigation report with the Health Board’s Quality and Safety Meeting for discussion and reflection on the identified failings.

Ms A complained that the Health Board had failed to respond to follow up correspondence, in which she clarified her concerns after receiving a formal complaint response. The Ombudsman found that the Health Board had failed to issue a further response to Ms A. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the agreement of the Health Board to provide a written response to Ms A in accordance with its concerns and complaints process, and to apologise for the delay in responding. The Health Board agreed to do this within 6 weeks of the Ombudsman’s decision.

Mr B complained that Cardiff and Vale University Health Board had failed to respond to the complaint made to it in June 2024 about the care and treatment provided to his late father. The Ombudsman found that there had been delays in the complaint response being issued and the Health Board had failed to appropriately update Mr B and his family, which the Ombudsman said caused frustration to them. The Ombudsman decided to settle the complaint without a formal investigation. The Ombudsman sought and gained the Health Board’s agreement to apologise and explain the reasons for the delay and lack of updates, to offer Mr B a redress payment of £250, and to issue its complaint response within 4 weeks.

Mrs X complained that Cardiff and Vale University Health Board failed to respond to her follow up concerns regarding her daughters treatment. The Ombudsman found that there had been a delay in the Health Board responding to Mrs X concerns. She said this caused uncertainty and frustration for Mrs X. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to, within 2 weeks, write to Mrs X with an apology and explanation for the delay and to issue its complaint response.

Miss C complained about the care and treatment her late mother, Mrs B, received from Cardiff and Vale University Health Board when she was admitted to University Hospital of Wales in January 2024. The investigation considered whether appropriate nursing care was provided to assess, monitor and prevent deterioration of Mrs B’s skin integrity. It also considered whether appropriate nursing care was provided to ensure Mrs B had appropriate fluid intake. The investigation found there were failings in the nursing care provided to Mrs B in relation to maintaining her skin integrity. This complaint was upheld. The investigation also found that it was appropriate that Mrs B was not prescribed IV fluids and she was appropriately supported with fluid intake. This complaint was not upheld. The Health Board agreed to apologise to Miss C. It also agreed to share the investigation report with nursing staff to highlight the failings identified, to remind staff to ensure that assessments are undertaken fully and appropriately documented, and to remind staff of the importance of re-positioning a patient.

Ms A complained about the response she received from Cardiff and Vale University Health Board, to her complaint that delays to her pregnancy dating scan meant she was unable to have further screening tests because the scan took place after week 14 of her pregnancy. The Ombudsman decided that the complaint response the Health Board had issued, did not fully address Ms A’s complaint. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement that within 1 month it would send a further response addressing the outstanding issues.

Ms L complained that Cardiff and Vale University Health Board failed to respond to her complaint which was submitted in December 2024. The Ombudsman found that the Health Board failed to issue update/holding letters during its investigation. This caused additional uncertainty and frustration for Ms L. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to aim to respond to the complaint within 2 weeks. If the response is not issued, it agreed to issue monthly update/holding letters until the response is issued.

Ms A complained that Cardiff and Vale University Health Board cancelled her thyroidectomy surgery on the day of the procedure because she was a smoker. Ms A was removed from the waiting list and referred for smoking cessation. Ms A said that the Health Board had not previously advised her of the need to stop smoking. The Ombudsman decided that the Health Board had not followed its policy in relation to smoking cessation. The information it had provided in writing was unclear, and it had not told Ms A of the requirement to stop smoking for the procedure to go ahead. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement within one month, to apologise to Ms A, to review the written information provided to patients in advance of their surgery to ensure it is clear and in line with the Health Board’s policy, and to confirm Ms A’s next appointment to discuss her care and treatment pathway.

Miss C complained about the care and treatment she received from the Health Board, specifically; • Whether the Commissioning Team appropriately considered requests received on her behalf between 2022 and 2023 • Whether it was clinically appropriate that she was repatriated to the Spinal Team in June 2022 and whether this decision was communicated to her appropriately and whether the Health Board’s monitoring/follow-up was appropriate following this decision (up until May 2023) • Whether the Health Board’s complaint response was compliant with Putting Things Right1 and whether the Spinal Team’s action post-complaint response (in reviewing Miss C and compiling a treatment plan) was undertaken in a timely manner. The investigation found that the Commissioning Team appropriately considered the funding requests made on behalf of Miss C and so this aspect of the complaint was not upheld. It would have been more appropriate for Miss C’s treatment to have continued at the Specialist Hospital in England and Miss C should have been informed about the decision to repatriate in June 2022 rather than May 2023. During this period no action was taken to arrange follow up locally. This delay undoubtably caused Miss C additional stress and anxiety. This aspect of the complaint was upheld. The investigation found that the Spinal Team’s actions post complaint response were undertaken in a prompt and appropriate manner with relevant investigations carried out and communicated to Miss C. However, the complaint response omitted to deal with Miss C’s overarching concern. Whilst it was factually accurate, it did omit to include the June 2022 request for repatriation which led Miss C to question the openness and transparency of the Health Board. The Health Board also failed to arrange a meeting as requested by Miss C which could have been beneficial in describing the bureaucratic and complex procedures and this could have led to an earlier resolution of the complaint. This aspect of Miss C’

Miss A complained that Cardiff and Vale University Health Board had not provided her with appropriate information about her father’s hospital admission, or the care and treatment provided to him. Miss A also complained that her father’s medical records could not be located, to inform the Health Board’s investigation of her concerns. The Ombudsman found that the response provided to Miss A by the Health Board did not clarify what medical records were missing to inform a full investigation. The Ombudsman considered that this caused Miss A uncertainty and frustration. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to provide Miss A with a comprehensive explanation of which records were available and missing at the time of the Health Board’s initial investigation, and to conduct a full investigation into the concerns raised by Miss A and provide her with a comprehensive response within 4 weeks. The Health Board also agreed to offer Miss A £250 financial redress for the uncertainty, in addition to the time and trouble taken to raise her complaint with the Ombudsman.

Ms A complained about the Health Board’s decision not to offer her an attention deficit hyperactivity disorder (“ADHD”) assessment, despite having previously had a private ADHD assessment and diagnosis. Ms A raised additional queries with the Health Board following its complaint response. As part of an early resolution settlement the Health Board agreed to provide a full and complete response to Ms A’s follow-up queries and to also consider the option of meeting Ms A.

An Advocate complained on behalf of Mrs A regarding the care that her daughter, Ms B, received from another health board (“the First Health Board”) and Cardiff and Vale University Health Board (“the Second Health Board”) in 2022. Specifically, Mrs A complained about the Second Health Board’s communication with her and the First Health Board about the funding arrangements for Ms B’s surgery. The investigation found that the care provided by the Second Health Board in relation to the funding arrangements reached an appropriate standard. As no failing was identified, the Ombudsman did not make any recommendations in regard to this complaint.

Ms C complained that Cardiff and Vale University Health Board had failed to adequately record and respond to complaints about her care, support and treatment. The Ombudsman decided that despite the efforts that Ms C had made to clarify her complaint, the Health Board had not provided a response which adequately addressed each of the points Ms C had raised. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman obtained a statement of complaint from Ms C and shared it with the Health Board. The Ombudsman then sought and gained the Health Board’s agreement to acknowledge the complaint within one week and investigate and respond to the complaint in accordance with the NHS Wales complaints procedure (Putting Things Right).

Mr A complained that Cardiff and Vale University Health Board (“the Health Board”) had failed to properly respond to a complaint he had submitted on behalf of his wife, in respect of delayed cataract surgery. The assessment found that whilst the Health Board had responded to Mr A’s complaint, it had not properly addressed the concerns he had raised. This amounted to maladministration, which caused Mr A an injustice. Instead of investigating the complaint, the Ombudsman obtained the Health Board’s agreement to investigate and fully respond to Mr A’s complaint, and to apologise for not doing so in the first instance. The Health Board also provided an assurance that it would be reviewing the content of its response letters to ensure that complainants were made aware that they could, when appropriate, go back to the Health Board if dissatisfied with its initial response.

Mrs A complained about the care and treatment that her late sister, Ms B received from the Health Board. This investigation considered whether given Ms B’s medication history and presenting symptoms, she should have been tested for fluoxetine toxicity1 to inform her diagnosis and/or before being prescribed additional medications and whether fluoxetine toxicity coupled with any other prescribed medication (specifically Oramorph) could have caused, or contributed to, Ms B’s cardiac arrest (when the blood supply to the heart is suddenly blocked). The investigation found that during Ms B’s admission she did not present with symptoms of moderate to severe fluoxetine toxicity. She did present with some symptoms of mild toxicity, however, these were also symptoms of the differential diagnoses. In light of this, and the fact that Ms B did not report an overdose, it was clinically reasonable that fluoxetine toxicity was not considered as a working diagnosis. Fluoxetine testing is not available in standard clinical practice. This aspect of the complaint was not upheld. The investigation did not find that fluoxetine coupled with any other medication caused Ms B’s cardiac arrest. However, it did identify concerns regarding the standalone prescription of Oramorph, given the failure to check Ms B’s blood pressure prior to its administration. The uncertainty surrounding this issue represented an injustice. This aspect of the complaint was upheld. (F/N 1 Ms B was prescribed fluoxetine by her GP. Fluoxetine increases the level of the chemical serotonin in the brain. Serotonin syndrome is a potentially fatal reaction that occurs when the body has too much serotonin. The terms fluoxetine toxicity and serotonin syndrome are used interchangeably in this report.) The Health Board agreed to: • Provide Mrs A with a written apology. • Develop an escalation process to ensure that failures to capture observations in deteriorating patients are escalated to appropriate clinicians. • Remind all

Ms A’s complaint centred on whether the care and treatment provided to her by the Health Board, and specifically its assessment and management of her risk of suicide and self-harm, on specified dates was appropriate. The Ombudsman’s investigation found that broadly the assessment and management of Ms A’s risk of suicide was reasonable. It is recognised that in Ms A’s case, the clinical situation was complex due to a number of presenting issues, including around her self-harming. However, in the absence of evidence of a serious mental health diagnosis, the assessment of risks and benefit undertaken by the mental health services had concluded that continued inpatient admission in the mental health unit increased Ms A’s risk of self-harming. It was felt that Ms A could benefit more from community based mental health support. Ms A’s further presentations and assessments did not change this clinical view. The Ombudsman’s investigation did identify isolated instances where documentation, for example, was not as good as it could have been. However, the Ombudsman found that this did not cause Ms A an injustice. On the evidence considered, Ms A’s complaint was not upheld. However, as a point of learning the Health Board was asked to consider the issues identified around documentation and look at introducing a specific policy relating to patients who refuse inpatient discharge if such a policy was not already in place.

Mrs F complained about whether Cardiff and Vale University Health Board (“the Health Board”) engaged appropriately with her when her mother, Mrs G, was an inpatient and whether it acted in accordance with relevant policies and regulations regarding Mrs F’s role as attorney for Mrs G. The investigation found that the Health Board did not engage appropriately with Mrs F while her mother was an inpatient. Mrs F was not informed when Mrs G was moved to a different hospital. Mrs F found out about changes to her mother’s treatment and condition by reading her medical notes. These were failings by the Health Board and a source of distress to Mrs F. The Health Board also did not act in accordance with relevant policies and regulations regarding Mrs F’s role as attorney for Mrs G. It did not take appropriate action when it was informed of Mrs F’s role as attorney or when discharge arrangements for Mrs G could not be agreed. These were failings by the Health Board and an injustice to Mrs F who will be left with lasting doubts about what the outcome may have been if policies and regulations had been followed. The Ombudsman upheld Mrs F’s complaint. The Health Board agreed to apologise to Mrs F and to offer her a payment of £750 in recognition of the distress and uncertainty caused by these failings. It also agreed to discuss the investigation with staff involved in Mrs G’s care in order for them to reflect on how Mrs F was communicated with. It also agreed to ensure that staff were familiar with the Health Board procedure regarding the role of attorneys and the policies and protocols to follow when seeking Deprivation of Liberty Safeguards authorisations.

Ms A complained about the delay in receiving a second opinion from a psychiatrist in relation to an autism diagnosis and the Health Board’s complaint handling, which included a delayed written complaint response. The Health Board agreed to apologise to Ms A again for shortcomings in complaint handling, which included an excessive delay in Mrs A receiving a written response. In recognition of the time and trouble and inconvenience caused to Ms A it agreed to pay redress of £100. It also agreed to provide Ms A with the information she had requested about the application of national clinical standards to the assessment process.