PSOW Individual Decisions

Mrs N complained about aspects of her mother, Mrs V’s, care at, and discharge from, Ysbyty Penrhos Stanley Hospital between November 2019 and May 2020. The investigation considered whether there was a delay in discharging Mrs V to a nursing home, whether there was a failure to support Mrs V in challenging a Deprivation of Liberty Safeguards (“DoLS”) authorisation, whether the Health Board relied on a health and welfare Lasting Power of Attorney (“LPA”) to justify a lack of communication with Mrs N and her brother, Mr B, whether it was appropriate to discharge Mrs V to a nursing home without consultation with Mrs N and Mr B or informing them of her new address, whether there was a failure to ensure the nursing home could meet Mrs V’s needs and whether the ending of the health funding arrangements took place without appropriate review. The Ombudsman found that there were good reasons for Mrs V’s discharge being delayed. The Health Board had acted reasonably in dealing with Mr A as the holder of the LPA with regard to the choice of a nursing home; it had ensured that the nursing home could meet Mrs V’s needs and reviewed the placement some 2 months later. The placement had been funded by a Welsh Government scheme to facilitate discharge of patients from hospital during the COVID-19 pandemic and this funding arrangement had remained in place. The Ombudsman did not uphold these parts of the complaint. However, the Ombudsman found there had been delays in the Health Board applying for urgent and standard DoLS authorisations, which meant the Relevant Person’s Representative was not appointed promptly. Mrs V was therefore deprived for a time of the opportunity of challenging the standard authorisation, which was an injustice to her and engaged her human rights. The Ombudsman upheld that element of the complaint. The Health Board agreed to apologise for these failings, ensure that staff were reminded of their legal obligations in ensuring DoLS applications were made without

Mrs K complained that Cyngor Gwynedd had failed to pay the statutory Heating/Cost of Living Allowance announced by the Welsh Government to her sister’s estate. Mrs K also complained that the Council issued a summons to her late sister’s estate for unpaid Council Tax, despite a block on recovery pending resolution of a Probate, and the inability of the Council to properly consider outstanding issues and communicate with her, which included dealings with 2 senior officers. The Ombudsman was concerned that Mrs K had not received a further response to her complaint by the Head of Service and that she had been inconvenienced by the Council’s actions. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Council’s agreement to provide Mrs K with an apology for the delay in providing a further response to her complaint, an explanation for the delay, and provide Mrs K with a further complaint response from the Head of service, within 4 weeks.

Mrs A complained about the care and treatment her late mother, Mrs B, received, after transfer from the Royal Gwent Hospital (“the First Hospital”), during an admission to Ysbyty Ystrad Fawr (“the Second Hospital”) between 19 August and 8 September 2020. She complained that the Welsh Government’s COVID-19 guidance about visiting Mrs B at the Second Hospital was not followed, Mrs B’s nutrition and medication during the final weeks of her life were not managed, there was a failure to have managed Mrs B’s deterioration and to provide appropriate and dignified end of life care. Mrs A also complained that Mrs B’s medical records were not accurately maintained. The Ombudsman found that the Health Board acted in accordance with guidance about access to the Second Hospital by visitors during the COVID-19 period. She found that Mrs B’s deterioration was managed in an appropriate and dignified manner and there were no significant shortcomings in the quality of Mrs B’s medical records. The Ombudsman found that, aside from one prescribing error (brought about by a lack of communication between the First and Second Hospital) which had not had any adverse clinical outcome, the management of Mrs B’s nutrition and medication was appropriate. She invited the Health Board to reflect on the failure to ensure adequate transfer of clinical information between the hospitals. The Health Board acknowledged this failure and has implemented an electronic handover document for patients, backed up by a hand over between ward teams. The Ombudsman did not uphold the complaints.

In 2019 Mr N complained to the Ombudsman about the Brecon Beacons National Park Authority’s (“the NPA”) delay in its response to his complaint, which had taken almost 3½ years to determine, and the actions taken by the NPA to implement the recommendations contained in the Monitoring Officer’s report of the investigation of the complaint. These included carrying out work to resurface a track and move/replace a cattle grid, as well as fencing on common land (which required the consent of the Welsh Government). The Ombudsman upheld Mr N’s complaint, and in the resulting report of 16 September 2019 made a number of recommendations intended to ensure that the actions were completed “as soon as reasonably practicable”, which the NPA agreed to implement. In September 2021 Mr N complained to the Ombudsman again about the lack of progress. The complaint was settled on the basis of the NPA agreeing to complete the work on the track and cattle grid by the end of March 2022, and to complete the fencing within 3 months of the Welsh Government’s consent for the work. By the end of October 2022, although work had been carried out, it had not been completed, and the application to the Welsh Government had “timed out” and needed to be re-submitted. Being dissatisfied that the NPA had not complied with the recommendations of the 2019 report or the terms of the settlement, the Ombudsman invoked her powers under section 28 to issue a Special Report. Although the Ombudsman understood that the NPA had at times found itself in a difficult position, the situation had been allowed to drift for far too long and it was wholly unacceptable that the matter had not been concluded. She recommended that the NPA, within 1 month: a) Issues a written apology to Mr N from the Chief Executive for the way in which the NPA has handled this matter. b) Pays Mr N the sum of £1000 in recognition of the time and trouble to which he has been put in pursuing his complaint. The Ombudsman also recommended that th

Mrs A complained on behalf of her late husband, Mr B, about the treatment and care provided by the Health Board on his admission to hospital in September 2020.  Mrs A said that the Health Board failed to protect Mr B from contracting COVID-19 while in hospital and to undertake a timely infection prevention investigation in response to her complaint. The Ombudsman’s investigation found that Mr B’s COVID-19 infection fell into the indeterminate classification in accordance with the Welsh Government’s National Framework for investigating possible cases of hospital acquired COVID-19.  This meant that no-one could say if Mr B was already incubating COVID-19 on admission or if he had acquired it in the hospital.  Although Mrs A said that the Health Board had not acted appropriately to minimise the risk of infection by testing patients for COVID-19 on admission to hospital, this was not recommended practice until January 2021.  Taking into account the unprecedented impact of the pandemic on the Health Board’s resources and the requirement to implement the National Framework, the time taken by the Health Board to respond to Mrs A’s concerns was not thought to be unreasonable. The investigation of Mrs A’s complaint was discontinued as there was little further of value that could be achieved through an ongoing enquiry into these matters

Mr X complained that: • His late mother had been eligible for NHS Continuing Health Care (CHC) funding. • That there had been a delay in the Health Board determining the retrospective CHC claim. • That the Health Board had not fully responded to the complaint about shortcomings in assessment and care provision for his mother at the time. The Ombudsman noted that Mr X’s original complaint and claim for retrospective CHC funding for his mother had been made in February 2020. This letter had also contained concerns about the lack of appropriate assessment and care provision for her in the preceding months. The Health Board acknowledged the delay in dealing with the claim but had explained that this was due to the focus on essential services during the COVID-19 pandemic (which was in line with Welsh Government guidance at the time). The Health Board agreed to : • Update Mr X’s family every month about the progress of the retrospective CHC claim (until its conclusion) • Provide a written response to Mr X’s complaint about the lack of proper assessment and care provision for his mother between April 2019 and February 2020, within 30 working days of the date of this decision, in line with the provisions of Putting Things Right.

Mr X complained about the way his application for Discretionary Assistant Funding (“DAF”) was handled. DAF had initially advised Mr X that his application was granted but after discovering an administrative error, it found that he was not eligible for funding and the application was consequently rejected. The Ombudsman found that DAF had failed to explain the change of decision. It therefore agreed to write to Mr X, by 21 September 2022, to explain the administration error and offer its apologies.

Mr A complained that the Surgery had insisted he wear a face covering (mask) before he would be seen at the Surgery even though Mr A said he was exempt from mask wearing as he was autistic. He said this had caused him anxiety and distress. It had also resulted in him not seeing a GP or getting his medication. In considering the case, the Ombudsman noted that autism is covered by the Equality Act 2010 and so Mr A would fall into the exemptions from mask wearing envisaged in Welsh Government guidance (issued during the COVID-19 pandemic). The Surgery’s response to Mr A’s formal complaint had said that exemptions did not apply in GP practices given their high-risk nature as a setting. Otherwise, the Surgery said that Mr A had been seen and had been issued with necessary medications. The Ombudsman examined Mr A’s clinical records and found that he had been seen in person, more than once, during the period concerned, as well as undergoing online consultations. He had been issued with relevant prescriptions. However, whilst it was mandatory to wear masks in healthcare settings at the time covered by the complaint, Welsh Government guidance plainly said that exemptions could still apply. It appeared the Surgery’s practice had been restrictive in this respect. This had caused distress and so injustice to Mr A when attending the Surgery premsies. As an alternative to a full investigation of the complaint, the Surgery agreed to undertake the following within 1 month: Apologise in writing to Mr A for the failure to acknowledge his exemption from wearing a face covering, and for the misinformation contained in the Surgery’s response to his complaint about exemptions in healthcare settings. Issue a reminder to Surgery staff about the Welsh Government’s guidance on exemptions – including that autistic people and others whose conditions are not visible may still be exempt.

The Ombudsman received a self-referred complaint from a Member (“the Former Member”) of Ceredigion County Council (“the Council”), that they had breached the Council’s Code of Conduct for members. The Member said that during a discussion at a public Council meeting about Welsh Ambulance Service NHS Trust (“WAST”) provision in Ceredigion, they had made inappropriate comments about “incomers” to the county and “immigrants” being allowed into Wales by the Welsh Government and the potential impact on those services. The Ombudsman’s investigation considered whether the Former Member’s conduct may have breached paragraphs 4(a), 4(b) and 6(1)(a) of the Council’s Code of Conduct. Information was obtained from the Council including a transcript of what the Former Member had said in the meeting, minutes of Council meetings, and comments from the Former Member. The Ombudsman found that following the incident the Former Member had stepped down from their political party to sit as an independent member. During the investigation the Former Member stood in the election on 5 May 2022 and was not returned by the local electorate. In comments to the Council and the Ombudsman, the Former Member said the remarks had been inappropriate and taken in a way not intended. The Ombudsman found that the Former Member’s remarks did not extend to gratuitous or personal comment or hate speech and would not have been interpreted as representative of the views of the Council. As such, they would not have amounted to a breach of paragraphs 4(a) or 6(1)(a) of the Code of Conduct. The Ombudsman determined, however, that they could be considered divisive and disrespectful, and suggestive of a breach of paragraph 4(b) in failing to show respect and consideration for others. The Ombudsman considered that, as the Former Member’s role was ultimately decided by the local electorate and they were no longer a member of the Council, any sanction which could be given if a breach of the Code of Conduct was found

Mr X complained that the Health Board had failed to prescribe him a newly approved medication called Fampridine, a drug used to improve walking ability in patients with multiple sclerosis. Mr X said this resulted in him paying for private prescriptions when he should have received the treatment from the NHS. The Ombudsman found that the Health Board had not adequately responded to Mr X’s concerns around the All Wales Medicine Strategy Group (AWMSG) guidance supported by Welsh Government that medicines should be available for prescription within 60 days. The Health Board agreed to an early resolution of Mr X’s complaint which included: Within 20 working days of the date of this letter, the Health Board will: 1. Write to Mr X to apologise for the inconvenience in needing to bring the matter to the Ombudsman before a resolution could be agreed 2. Reimburse Mr X for the cost of the medication he self-funded during the period March 2020 to July 2021, subject to Mr X being able to provide full documentation supporting the payments made during this time. Within 40 working days of the date of this letter, the Health Board will: 3. Conduct a review of all current Multiple Sclerosis patients to ensure there are no other patients who have been similarly self-funding this medication. It is noted Mr X has requested a refund from January 2020 but the 60 days allowed by AWMSG means it is reasonable to refund from March 2020.

Mrs T complained that the Adult Safeguarding Team (“the AST”) at Wrexham County Borough Council (“the Council”) mismanaged 4 Safeguarding referrals it received in respect of her late friend, Mr D – for whom Mrs T held Lasting Power of Attorney for Health and Welfare (“an LPA”). The referrals alleged that Mr D, who had progressive dementia, suffered abuse/was at risk of abuse from Mrs T as the result of her interactions with him (following his placement in a Care Home). Mrs T complained that: 1. The Safeguarding referrals should not have met the threshold for investigation as they were vexatious in nature. 2. The Safeguarding investigations were not conducted in accordance with the Social Services and Wellbeing (Wales) Act 2014. 3. A Safeguarding officer inappropriately reported the received referrals to the Office of the Public Guardian (“the OPG”), which is responsible for registering and regulating LPAs. 4. Mr D was not informed of the referrals or of the subsequent investigations and so his views on the events in question were not obtained. Also, evidence was not obtained from witnesses whose input might have favourably influenced the investigations. 5. Mrs T was not updated on the progress or conclusions of the investigations. The Ombudsman did not uphold any of Mrs T’s complaints. His investigation found that: 1. There was no evidence that the referrals, as received, were vexatious in nature. The AST was obliged to investigate whether Mr D was an adult at risk and (in 2 of the 4 referrals) recommended appropriate protective measures to restrict Mrs T’s contact with Mr D. 2. The Ombudsman found that the AST dealt with the referrals it received in accordance with procedures set out in Part 7 of the Social Services and Wellbeing (Wales) Act 2014 (and in accordance with Volume 6 of statutory guidance issued by the Welsh Government). 3. The Ombudsman found that the decision to report the received referrals to the OPG was not unreasonable (as the regulator of LPAs).

Mr N complained about the failure of the Authority to carry out works which it had agreed to do and which were the subject of a previous Ombudsman’s report. The works required planning permission, and permission from the Welsh Government to carry out work on common land. The Ombudsman’s enquiries of the Authority showed that, although there had been considerable delay on the part of the Authority, which he considered amounted to maladministration, the Authority had carried out a tender exercise for some of the works, and was awaiting consent from the Welsh Government for the remainder. The Authority agreed to complete the works included in the tender by the end of March 2022, and to complete the remainder of the works within 3 months of the Welsh Government issuing its consent for the work. The Ombudsman considered this to be a reasonable settlement of Mr N’s complaint.

The Ombudsman investigated 3 complaints made to him by 3 members of the public about a Member (“the Member”) of Pembrokeshire County Council (“the Council”). It was alleged by the first complainant that the Member had suggested on social media that a fellow Member of the Council had an interest in children and had shared images of a child.  It was also alleged that the Member had wrongly alleged that the first complainant had served time in prison. It was alleged by the second complainant that the Member had posted misleading information about the Welsh Government’s Relationships and Sexuality Education (“RSE”) curriculum on social media. It was alleged by the third complainant that the Member had suggested on a public Facebook post that the third complainant was on the sex offender’s register. The Ombudsman found that the Member had wrongly stated that a fellow Member of the Council had shared an explicit pornographic video of a girl under the age of 17 when that Member was 18.  The Ombudsman also found that the Member had wrongly alleged on social media and in emails to his office that the first complainant had served time in prison. The Ombudsman considered that the content of social media posts made by the Member in respect of the RSE curriculum were not factual and were misleading. The Ombudsman also found that the Member had falsely suggested on a public Facebook post that the third complainant was on the sex offender’s register. The Ombudsman also determined that the Member had attempted to mislead him during the investigation. The Ombudsman concluded that the Member’s conduct may amount to a breach of paragraphs 4(c) and 6(1)(a) of the Council’s Code of Conduct and referred his report to the President of the Adjudication Panel for Wales for adjudication by a tribunal. The Adjudication Panel for Wales found that the Member had breached paragraphs 4(c) and 6(1)(a) and disqualified him for 3 years.

The Ombudsman investigated 3 complaints made to him by 3 members of the public about a Member (“the Member”) of Pembrokeshire County Council (“the Council”). It was alleged by the first complainant that the Member had suggested on social media that a fellow Member of the Council had an interest in children and had shared images of a child.  It was also alleged that the Member had wrongly alleged that the first complainant had served time in prison. It was alleged by the second complainant that the Member had posted misleading information about the Welsh Government’s Relationships and Sexuality Education (“RSE”) curriculum on social media. It was alleged by the third complainant that the Member had suggested on a public Facebook post that the third complainant was on the sex offender’s register. The Ombudsman found that the Member had wrongly stated that a fellow Member of the Council had shared an explicit pornographic video of a girl under the age of 17 when that Member was 18.  The Ombudsman also found that the Member had wrongly alleged on social media and in emails to his office that the first complainant had served time in prison. The Ombudsman considered that the content of social media posts made by the Member in respect of the RSE curriculum were not factual and were misleading. The Ombudsman also found that the Member had falsely suggested on a public Facebook post that the third complainant was on the sex offender’s register. The Ombudsman also determined that the Member had attempted to mislead him during the investigation. The Ombudsman concluded that the Member’s conduct may amount to a breach of paragraphs 4(c) and 6(1)(a) of the Council’s Code of Conduct and referred his report to the President of the Adjudication Panel for Wales for adjudication by a tribunal. The Adjudication Panel for Wales found that the Member had breached paragraphs 4(c) and 6(1)(a) and disqualified him for 3 years.

The Ombudsman investigated 3 complaints made to him by 3 members of the public about a Member (“the Member”) of Pembrokeshire County Council (“the Council”). It was alleged by the first complainant that the Member had suggested on social media that a fellow Member of the Council had an interest in children and had shared images of a child.  It was also alleged that the Member had wrongly alleged that the first complainant had served time in prison. It was alleged by the second complainant that the Member had posted misleading information about the Welsh Government’s Relationships and Sexuality Education (“RSE”) curriculum on social media. It was alleged by the third complainant that the Member had suggested on a public Facebook post that the third complainant was on the sex offender’s register. The Ombudsman found that the Member had wrongly stated that a fellow Member of the Council had shared an explicit pornographic video of a girl under the age of 17 when that Member was 18.  The Ombudsman also found that the Member had wrongly alleged on social media and in emails to his office that the first complainant had served time in prison. The Ombudsman considered that the content of social media posts made by the Member in respect of the RSE curriculum were not factual and were misleading. The Ombudsman also found that the Member had falsely suggested on a public Facebook post that the third complainant was on the sex offender’s register. The Ombudsman also determined that the Member had attempted to mislead him during the investigation. The Ombudsman concluded that the Member’s conduct may amount to a breach of paragraphs 4(c) and 6(1)(a) of the Council’s Code of Conduct and referred his report to the President of the Adjudication Panel for Wales for adjudication by a tribunal. The Adjudication Panel for Wales found that the Member had breached paragraphs 4(c) and 6(1)(a) and disqualified him for 3 years.

During another investigation into concerns raised by Mr Y, the Ombudsman received evidence from the Health Board which indicated that, at the time Mr Y was placed on the urgent list for prostate cancer treatment in August 2019, there were a total of 16 other patients with the same urgent clinical priority awaiting the same procedure(prostatectomy – surgery to remove the prostate). As I had reasonable suspicion there were other possible incidents of service failure and maladministration in relation to the other patients on the waiting list, I commenced an investigation using my own initiative power of investigation to consider whether the Health Board exceeded the Referral to Treatment Time (“RTT” – the waiting time management rules) target for cancer waiting times for treatment of prostate cancer in respect of the 16 patients who were awaiting prostatectomies. My investigation found that, in August 2019, the Welsh policy position in accordance with Welsh Government guidance was that, only patients treated in Wales were reported against the Welsh cancer waiting time targets. The Health Board therefore only produced “breach reports” and undertook harm reviews for the patients it treated. This did not apply to patients referred by the Health Board for treatment in England. Of the 16 patients on the waiting list in August 2019, 8 were referred to England for treatment. If they had been treated in Wales, the breaches of the target timescales would have been reported for all 8 patients because the amount of time they waited for treatment exceeded the 62 and 31-day target for cancer RTT (the target times relate to whether a patient had been designated as urgent suspected cancer or non-urgent suspected cancer). Four of the patients on the waiting list who were treated by the Health Board had exceeded the cancer waiting time target and these breaches of the target timescales were reported and harm reviews were completed. While the Welsh policy position at the time meant ther