PSOW Individual Decisions

Mrs B complained about the care her mother, Mrs A, received from the Health Board in 2023, specifically whether: Mrs A was given too much morphine following her documented fall on the GP Assessment Unit in April and that the Health Board subsequently failed to identify and treat a fracture of Mrs A’s coccyx (the bone at the base of the spine) between April and May. Mrs B also complained that an apparent second fall between 24 and 25 June, while Mrs A was on a ward, was avoidable and whether it was dealt with appropriately. Finally, she queried whether her complaint was dealt with appropriately and in line with the Health Board’s complaints procedure. The investigation found that there was no evidence to suggest Mrs A was given too much morphine and so this point of complaint was not upheld. Furthermore, the Health Board acted appropriately while seeking to diagnose whether Mrs A had a coccyx fracture and there was no evidence Mrs A suffered a fall between 24 and 25 June, so these points were not upheld. Finally, although the Health Board did not fully comply with the statutory complaint process, it provided Mrs B with a formal response to her complaint in accordance with the legislation. This point was not upheld.

Mr E complained that Cwm Taf Morgannwg University Health Board failed to respond to a complaint he submitted, by email, in April2025. The Ombudsman found that the Health Board had conducted a thorough search of Mr E’s email but it could not be located, although it was sent to the correct email address. This caused additional frustration and uncertainty for Mr E. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to write to Mr E, within 7 working days, to apologise that it could not locate his email. It also agreed to look into the complaint he raised.

Mrs A complained about the care and treatment provided to her father, Mr B, prior to his death, by Cwm Taf Morgannwg University Health Board (“the Health Board). On receipt of the final response, Mrs A had outstanding questions about her father’s treatment. The Ombudsman considered that the Health Board would be best placed to answer these, as the Body involved in his care. Mrs A did not wish to meet with the Health Board, as it had offered in its final response. The Ombudsman sought and gained the Health Board’s agreement, to within 2 weeks contact Mrs A to identify her concerns and outstanding issues to confirm the scope of its investigation, then within 30 working days of agreement to issue a response to any new concerns in line with the Putting Things Right regulations, and/or, within 30 working days of agreement to provide a response to any outstanding concerns which require clarification.

Ms L complained that Cwm Taf Morgannwg University Health Board failed to arrange her hip replacement surgery and that it had made excuses for the delay. The Ombudsman found that Health Board explained to Ms L the reasons for the delay but that it failed to keep her updated. This caused additional uncertainty and frustration for Ms L. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to write to Ms L, within 2 weeks, to apologise for the delay and to provide an update of developments.

Mr X complained that Cwm Taf Morgannwg University Health Board had failed to respond to the complaint he made to it in February 2025. The Ombudsman found that there had been a delay in the Health Board responding to Mr X and a failure to properly update him. The Ombudsman said this caused frustration to Mr X and 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 a £50 redress payment to Mr X and to issue its complaint response to him within 4 weeks.

Ms N complained that Cwm Taf Morgannwg University Health Board had failed to respond following an admission of a breach of duty of care in August 2024. The Ombudsman found that, whilst the Health Board acknowledged a breach of duty of care in August 2024 and that it would be investigating whether Qualifying Liability existed, it failed to communicate further with Ms N. This caused additional uncertainty for Ms N. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and agreed with the Health Board that it would progress this matter as priority. That it would, within 8 weeks conduct a full file review and execute a remedial plan of action.

Mr D complained that Cwm Taf Morgannwg University Health Board failed to respond to a complaint he submitted in March 2025. The Ombudsman found that whilst the Health Board is still within the time limits set out in the complaints process, it had failed to keep Mr D regularly updated. This caused additional frustration and uncertainty for Mr D. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Boards agreement to issue monthly update letters until its investigation is concluded.

Mr X complained that Cwm Taf Morgannwg University Health Board failed to respond to his complaint. The Ombudsman found that the Health Board had failed to respond to Mr X’s complaint. She said this caused uncertainty and frustration for Mr X. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to, within 30 working days, offer an apology and explanation to Mr X for the delay in responding to his complaint and issue its complaint response under the ‘Putting Things Right’ complaints procedure.

Mr A complained about the care and treatment his late wife, Mrs A, received from Cwm Taf Morgannwg University Health Board. The investigation considered whether a vascular referral should have been made following Mrs A’s review and investigations by the Rapid Diagnostic Clinic on 6 December 2022. The investigation found that even if a vascular referral had been made, no specific action would have been undertaken by a vascular specialist as Mrs A’s presentation did not merit any further treatment other than what she was already receiving. The complaint was not upheld.

Mrs B’s complaint centred on whether the care and treatment for depression and anxiety provided to her husband, Mr B, by the Princess of Wales Hospital between 6 and 15 September 2023 was clinically appropriate. In particular, whether action taken to risk assess, explain side effects of medication and the level of contact with professionals was adequate. Mr B committed suicide on 16 September. The Ombudsman’s investigation found that although there were aspects of the assessment that was carried out on Mr B on 6 September that were in keeping with relevant guidance in terms of the treatment offered, there were clinical shortcomings in the process. This included issues around patient discussion of the medication plan and the side effects, Mr B’s risk assessment, collaboratively working with the GP and the information provided to the GP. There were also clinical and administrative shortcomings in relation to the telephone contact with Mr B on 15 September, with no documented evidence of a risk assessment being completed by the Psychiatric Doctor despite Mr B’s reference to “not coping”. The investigation concluded that even if the clinical failings identified had not occurred this did not mean that the decisions around medication and discharging Mr B back to his GP care would have changed or that Mr B’s management would have been any different. However, there remained a possibility that decision making may have been different and this represented an injustice for Mrs B and her family who have to live with the uncertainty of not knowing whether the sad outcome in relation to Mr B might have been different but for the clinical failings identified. Therefore, it was to this extent that Mrs B’s complaint was upheld. The Health Board accepted the Ombudsman’s recommendations which included an apology to Mrs B for the failings identified in the report and learning and process changes including improved documentation and better risk assessments. The Health Board also agreed t

Mrs A complained because she was unhappy with Cwm Taf Morgannwg University Health Board’s care and treatment of her late husband. Mrs A’s husband sadly died in July 2024. The Ombudsman noted that the Health Board had provided a complaint response, including investigation report, in February 2025.However, Mrs A had raised several queries about the response and a meeting was being arranged to discuss these. However, the Ombudsman also noted that Mrs A had originally raised concerns in 2022 and 2023. There was a significant delay in Mrs A receiving a response to her complaint. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to, within 2 weeks, provide an apology to Mrs A for the delay in providing a complaint response and to offer a financial redress payment of £250.

Mrs C complained about the care and treatment her late mother, Mrs B, received from Cwm Taf Morgannwg University Health Board (‘the Health Board’) when she was admitted to Prince Charles Hospital between 22 and 26 April 2024. The investigation considered Mrs C’s complaint that Mrs B did not receive a reasonable standard of care including insufficient monitoring and medication for pain and agitation, delays in medical assessment and referral to a suitable ward for end-of-life care. The investigation also considered Mrs C’s complaints that Mrs B was supported to orally eat and drink when it was unsafe, and she required an assessment by the Speech and Language Team (‘SALT’), and that the Health Board’s complaint response was compromised by factual inaccuracies. The investigation found that there were failings in the care provided to Mrs B including in relation to monitoring Mrs B’s pain, and delays in using a syringe driver (a device used to deliver medication under the skin), administering medication and in referring Mrs B to an appropriate ward. These complaints were upheld. While it was found that the referral to the SALT was not actioned, it was found that this did not cause any harm to Mrs B and this complaint was not upheld. Finally, failures were identified in the handling of Mrs C’s complaint and this was upheld. The Health Board agreed to apologise to Mrs C for the failings identified. It also agreed to share the findings of the investigation with relevant staff and remind staff to use appropriate pain assessment stools, to complete accurate record keeping, and ensure timely actions are taken following medical reviews. It also agreed to review its handling of Mrs C’s complaint.

Ms D complained that Cwm Taf Morgannwg University Health Board failed to respond to her complaint about how it communicated with her when conducting a Situation, Background, Assessment Recommendation review into her late father’s, Mr D’s, care. Some elements of Mr D’s care and treatment were also being considered under the NHS Redress Scheme. The Ombudsman decided that the matters raised in Ms D’s complaint, which were not being considered under the Redress Scheme, required a complaint response. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement that within 2 weeks it would write to Ms D to apologise for the lack of communication, and within 3 months it provide a complaint response for the elements that sat outside of the Redress Scheme.

Mrs C has complained about the standard of care provided to her by Cwm Taf Morgannwg University Health Board when she was an inpatient at Prince Charles Hospital (‘the Hospital’) in November 2022. The Ombudsman’s investigation specifically considered whether, during Mrs C’s November 2022 admission, appropriate investigations were carried out, and there was proper consideration of a diagnosis of a stroke, and whether it was appropriate to give Mrs C venlafaxine (a drug to treat anxiety, panic attacks, depression) at the dose given (225mg) when she said that she did not take it any longer. The investigation found that Mrs C received a thorough history and neurological examination and appropriate imaging, in line with clinical guidance. Proper consideration was given to whether Mrs C had suffered a stroke, but the results from her examinations and imaging did not support this. Furthermore, that it was appropriate that Mrs C was given venlafaxine 225mg based on the information she gave to the clinicians at that time, as recorded in the medical records. The Ombudsman did not uphold these complaints.

Mrs X complained that Cwm Taf Morgannwg University Health Board had failed to respond to her complaint. The Ombudsman found that there had been a delay by the Health Board to respond to Mrs X’s complaint. She said this caused inconvenience and frustration for Mrs X. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the agreement of the Health Board to provide Mrs X with a complaint response that will also include an apology for the delay and an explanation as to why this happened within 10 days.

Mr A complained that he was unhappy with a delay of 3 years in waiting to receive care and treatment from Cwm Taf Morgannwg University Health Board’s (‘the Health Board’) Weight Management Service. Mr A was also unhappy with the Health Board’s complaint response. He said that it had not addressed all of the issues he had raised. The Ombudsman decided that the Health Board had not explained to Mr A that it considered his outstanding concerns to be out of time under the complaints process. The Ombudsman also decided that the Health Board had information about the Weight Management Service that may assist Mr A in understanding why he has had to wait for care and treatment. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement, within 1 month, to apologise to Mr A that he was not informed that aspects of his complaint were out of time, to provide Mr A with information about the capacity of the Weight Management Service, and to provide Mr A with an update on the current waiting list.

Ms C complained that Cwm Taf Morgannwg University Health Board failed to provide a final response and that there had been significant delays. The Ombudsman found that the Health Board had yet to provide the final response and that there had been delays which caused additional frustration and uncertainty for Ms C. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to write to Ms C within 1 month with an apology and explanation for the delays, an offer of a £150 financial redress payment and an update on the progress of the final response. It has also agreed to provide the final response to Ms C within 6 months.

Mrs C has complained about the care and treatment her son, B, received from Cwm Taf Morgannwg University Health Board. Specifically, Mrs C complained about whether the time taken to carry out cardiac investigations for B following his admission to the Paediatric Unit at Prince Charles Hospital on 28 June 2023 was clinically appropriate. The investigation found that, based on B’s clinical presentation, he was appropriately managed during his admission to the Hospital between 28 June and 1 July 2023. The complaint was not upheld.

Mr A complained that Cwm Taf Morgannwg University Health Board (“the Health Board”) dealt with his complaint, about communication about the waiting time for a hip replacement operation, under its early resolution process. Mr A had requested a formal response from the Health Board under Putting Things Right. The Ombudsman decided that whilst the Health Board had provided a full complaint response to Mr A, he had spent considerable time and effort in contacting the Health Board, in order to receive a formal response. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement within 1 month to make a redress payment of £250 to Mr A, for the time and trouble taken to get a formal response to his complaint.

Mr M complained that Cwm Taf Morgannwg University Health Board had failed to respond to his follow up concerns arising from the complaint response he received in August 2023. The Ombudsman decided that there had been a significant delay by the Health Board to provide Mr M with a follow up response. She said this had caused frustration and uncertainty for Mr M. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to apologise to Mr Mand provide him with a full explanation for the delays. The Health Board also agreed to offer Mr M a redress payment of £200 and to issue a complaint response within 6 weeks.

An Advocate complained on behalf of Mrs A regarding the care that her daughter, Ms B, received from Cwm Taf Morgannwg University Health Board (“the First Health Board”) and another health board (“the Second Health Board”) in 2022. Specifically, Mrs A complained about the manner in which the funding request for Ms B’s surgery was administered by the First Health Board and its communication with her and the Second Health Board in that regard. The investigation found that there was confusion within the First Health Board regarding the process for arranging funding between itself and the Second Health Board. It also failed to communicate appropriately with Mrs A and Ms B, and the Second Health Board, regarding the outcome of the funding application in respect of Ms B’s surgery. This constituted maladministration and the resultant uncertainty over whether it had been granted was an injustice to Mrs A and Ms B. The complaint was therefore upheld. The First Health Board agreed to the Ombudsman’s recommendations to apologise to Mrs A and Ms B for its maladministration and to pay Mrs A redress of £250 in recognition of the time and trouble that she experienced in bringing this complaint on behalf of Ms B. It also agreed to pay Ms B redress of £500 in recognition of the significant stress and frustration she underwent during the funding application process due to its failing. Finally, the First Health Board agreed to review and amend its communication process following the outcome of a Prior Approval funding application, ensuring its new process includes timely confirmation of the outcome to both patient and the authority that will provide the treatment.

Mrs A complained to Cwm Taf Morgannwg University Health Board about the care and treatment provided to her son following him fracturing his elbow. She also raised concerns about the lack of a clear, robust pathway for 16–18-year-olds with additional needs to receive treatment. The Ombudsman found that the Health Board’s complaint to Mrs A did not comply with the National Health Service (Concerns, Complaints and Redress Arrangements) (Wales) Regulations 2011. Neither did it address the concerns Mrs A raised about wider service provision. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to Provide a comprehensive response (in accordance with the National Health Service (Concerns, Complaints and Redress Arrangements) (Wales) Regulations 2011) to Mrs A’s complaint within 6 weeks.

Miss X complained that Cwm Taf Morgannwg University Health Board failed to respond to the complaint she submitted in September 2024 regarding her late father’s treatment in hospital. The Ombudsman found that there was a communication failure and, as a result of this, Miss X had not received a formal complaint response. The Ombudsman said this caused uncertainty and frustration for Miss X. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to, within 2 weeks, offer an apology to Miss X for the communication failure and explain why it happened, in addition to forwarding Miss X a complaint and consent form. The Health Board also agreed to issue the complaint response within 6 weeks of receiving the complaint and consent form from the complainant.

Miss Y complained that the decision by Cwm Taf Morgannwg University Health Board to discharge her grandmother, Mrs Z, home from hospital on 16 February 2023 was inappropriate. She said the Health Board did not assess: • Mrs Z’s ability to carry out activities of daily living at home. • Mrs Z’s mental capacity to decide whether to go home. The investigation found that Mrs Z was appropriately assessed prior to her discharge from hospital. On this basis, the complaint was not upheld.

Miss C complained to Cwm Taf Morgannwg University Health Board (“the Health Board”) about her management and care in relation to her pregnancy loss on 2 August 2023 and queried whether it was clinically appropriate. The Ombudsman’s investigation found that there were instances when nursing care fell below an acceptable standard. The Ombudsman was concerned that given Miss C’s blood loss and dizziness, as noted in the retrospective nursing entry, her vital observations were not taken, as these would have highlighted her clinical deterioration and would have alerted the clinicians to the gravity of her condition. The investigation found that Miss C’s care should have escalated sooner and that there were missed opportunities to do so. The Ombudsman concluded that the service failings in this case were fundamental, and to that extent, unacceptable and resulted in significant blood loss and a frightening near-death experience for Miss C and her partner causing them significant injustice. The investigation found that the shortcomings in nursing care were compounded by inadequate record keeping, which meant that clinicians undertaking Miss C’s care in the intervening period lacked information about the seriousness of her condition. The Ombudsman was concerned that the Health Board’s investigation did not identify failings in the care and management Miss C received on 2 August, including the shortcomings in nursing care and record keeping. Given these administrative shortcomings and service failings, Miss C’s complaint was upheld. In terms of complaint handling, the Ombudsman found that the Health Board did not identify failings in Miss C’s care and management (on 2 August) and this reflected a lack of diligence and rigour in the investigation process. It also meant opportunities were missed to properly learn lessons and put things right quickly and effectively. The Ombudsman made a number of recommendations which included the Health Board apologising to Miss C for clinical