PSOW Individual Decisions

Miss A complained regarding the treatment her sons received at the Orthodontic Clinic. The Ombudsman found that, while the Clinic had been in email correspondence with Miss A, it had failed to provide a formal complaint response via the complaint procedure. The Ombudsman said this caused uncertainty and frustration for Miss A. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Clinic’s agreement to, within 3 weeks, provide the final complaint response, along with an apology and to explain why the complaint was not responded to in line with the formal complaint procedure.

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

Mr C complained that Betsi Cadwaladr University Health Board had failed to progress a referral to the Posture and Mobility Service, to assist him while he was waiting for knee replacement surgery. The Ombudsman decided that the communication from Mr C’s doctor had been contradictory and that Mr C had been led to believe a referral had been made, when it had not. When the Health Board investigated Mr C’s complaint, it did not contact the doctor and relied solely on the limited information held by the Posture and Mobility Service. There was a missed opportunity to clarify and resolve the issues when the Health Board declined a request for a meeting to discuss Mr C’s concerns. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to send a referral form to Mr C’s GP for completion within 4 weeks. The Health Board also agreed to apologise for not investigating Mr C’s complaints sufficiently thoroughly, provide feedback to the doctor and prioritise consideration of the referral, when it was received.

Mr A complained that Aneurin Bevan University Health Board had failed to respond to his complaint and it had failed to keep him updated. The Ombudsman found that the Health Board had not responded to Mr A’s complaint and it had failed to keep him updated. She said this caused uncertainty and frustration for Mr A. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to, within 3 weeks, offer an apology and explanation, issue its response and offer £150 financial redress in recognition of the delays and lack of updates.

Mr A complained that the GP Practice failed to provide appropriate care prior to his removal from its patient list. The Ombudsman found that, while the GP Practice had addressed Mr A’s concerns about being removed from the patient list, it had not provided a full written response regarding concerns he had raised about his care. This caused frustration and uncertainty for Mr A. The Ombudsman decided to settle the complaint without a formal investigation. The Ombudsman sought and gained agreement from the GP Practice to provide a comprehensive written response to Mr A’s concerns by 20 April 2026.

Ms A complained about the standard of care provided to her late father, Mr B, when he was admitted to hospital in February 2024 due to swallowing issues. The Ombudsman’s investigation considered whether, during Mr B’s inpatient stay on an ENT ward, appropriate medical care and interventions were provided in a timely manner. The Ombudsman found that the medical care, and the Gastroenterology investigations and procedures which were carried out, were all reasonable to address Mr B’s clinical presentation and symptoms. There was a delay in the initial Gastroenterology review, and the subsequent transfer to a Gastroenterology ward. However, the Ombudsman found that this did not affect Mr B’s medical management, the treatment options that were open to him, or the outcome of that treatment. The complaint was therefore not upheld.

Ms A complained that she had not received a suitable response to her complaint which she submitted to Powys Teaching Health Board (“the Health Board”). She said that the specific questions she raised had not been addressed sufficiently or at all. The Ombudsman found that although the Health Board had provided a detailed and comprehensive response to about the care received by Ms A’s mother, it did not adequately address Ms A’s questions. The Ombudsman was also concerned that following the complaint response the Health Board told Ms A on 25 November 2025 that she would receive post-response correspondence which addressed her questions with 2 weeks. At the time the complaint was brought to the Ombudsman (2 March 2026), no such response had been received. The Ombudsman decided to settle the complaint without an investigation on the basis that within 2 weeks of issuing the decision letter the Health Board would issue Ms A a complaint response which provides a comprehensive answer to the 6 questions she raised in her original complaint.

Mrs A’s complaint centred on whether the GP Practice failed to recognise her signs of heart failure and carry out appropriate investigations and a timely referral because it misdiagnosed her shortness of breath as asthma for 9 months between February and October 2024. The Ombudsman did not uphold Mrs A’s complaint. The investigation found that Mrs A’s asthma management was appropriate and that there was no objective clinical evidence to suggest that she had heart failure before October 2024.

Mrs B was concerned that, despite her husband, Mr B, experiencing significant pain in his abdomen and ribs in 2024, clinicians at the GP Practice missed signs of lung cancer symptoms, resulting in a delay in the diagnosis of his cancer. The investigation focused on whether clinicians at the GP Practice acted appropriately when Mr B presented with pain in his abdomen and ribs between July and August 2024. The investigation found that at each of the consultations between July and August 2024, the examinations, possible diagnoses, treatment and actions of the clinicians were within the range of acceptable clinical practice. There was no indication that Mr B should have been referred for a chest X-ray for possible suspected lung cancer before the end of August. The investigation also found that while clinicians appropriately considered Mr B’s history of prostate cancer, including a normal PSA reading in May 2024, prostate cancer was not the cause of Mr B’s lung cancer. The complaint was not upheld.

Ms E complained about the standard of care provided to her adult daughter, Ms F, by one of the Health Board’s community mental health teams (“the CMHT”). The Ombudsman’s investigation considered whether: a) Whether the psychology approach in undertaking exposure therapy was appropriate. b) Whether the decision not to arrange an assessment for ADHD/ASD was appropriate. c) Whether the decision to discharge Ms F from the CMHT was appropriate. The Ombudsman found that the psychological therapy approach was in line with appropriate clinical practice and guidelines, based on Ms F’s presenting symptoms. This aspect of the complaint was not upheld. However, the Ombudsman was satisfied that there was evidence that a referral for an ASD assessment should have been made by the CMHT, and this aspect of the complaint was upheld. In relation to the decision to discharge Ms F from the CMHT services, this was not a clinically unreasonable decision. However, there were some shortcomings in how it was reached. Specifically, there was a lack of consultation with Ms F and an absence of clear information about the referral pathway for ASD assessment. This aspect of the complaint was partly upheld to that extent. The Health Board agreed to the Ombudsman’s recommendations which included an apology to Ms F for failing to refer her for an ASD assessment and to make that referral if Ms F still wished this. It also agreed to review its ASD/ADHD policies and referral pathways to ensure that they identify, and have clear pathways to refer, cases for ADHD/ASD assessment in line with NICE guidance (CG142) and the Quality Standard.

Mrs A complained that Aneurin Bevan University Health Board failed to issue a response to her complaint, made in November 2024, regarding the care and treatment provided to her. The Ombudsman found that the Health Board had not provided Mrs A with a complaint response and that this caused uncertainty and frustration for Mrs A. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to write to Mrs A with an apology and explanation for the delay, offer to pay £150 in recognition of the delay and to issue a complaint response. The Health Board agreed to do this within 1 month of the Ombudsman’s decision.

Mr B complained that he had raised a repair complaint but that no one had come to inspect or repair it. He said the concrete at the top of the path had broken down and was causing a slip/trip hazard. The Ombudsman found that the breakdown of the concrete had been raised at the same time as several other issues, and that it seemed to have gotten lost amongst the correspondence about Mr B’s other concerns. The consequence of this was not only that there appeared to have been a failure of communication, it also, potentially, amounted to a failure to inspect and carry out necessary repairs. The Council agreed that, within 1 month, it would arrange an inspection appointment to review the status of the concrete path and reach a decision as to whether a repair is required. It also agreed to apologise for not having addressed this issue previously.

Mrs B complained that Carmarthenshire County Council failed to adequately address her complaint about damp and large cracks in her walls. Mrs B also complained about the lack of communication from the Council. The Ombudsman found that the Council had failed to properly consider Mrs B’s complaint and its communication with Mrs B had fallen short of expected standards. She said that this caused frustration and uncertainty to Mrs B. She decided to settle the complaint without an investigation. It was noted that the Council had already provided an apology to Mrs B regarding the poor communication. As such, the Ombudsman sought and gained the Council’s agreement to write to Mrs B with an apology for the failure to properly consider her complaint, and to undertake a through investigation of all of Mrs B’s concerns and issue a properly considered Stage 2 complaint response within 4 weeks.

Mrs A complained about the neurology care she received from Betsi Cadwaladr University Health Board. This included care provided by an NHS Trust in England on behalf of the Health Board. The investigation considered the following: a) whether the Health Board adequately assessed and treated the cause of Mrs A’s tremor, taking into account potential interactions with prescribed medications b) whether Mrs A was inappropriately advised that she had an incurable condition that would prevent her from continuing to practice dentistry. The investigation found that there was no evidence that the possibility that Mrs A’s tremor had been made worse by a prescribed medication was considered or discussed with her. This should have been discussed with her even other if causes were considered much more likely. The Ombudsman upheld this complaint. The investigation found that the advice given about Mrs A’s ability to work was reasonable. Accordingly, the Ombudsman did not uphold this complaint. The Ombudsman recommended that the Health Board apologise to Mrs A and make a financial redress payment to her of £1,750. This included £750 in respect of the avoidable inconvenience and distress of living with the tremor for an additional 15 months. It also included £1,000 to reflect the potentially very significant impact of the loss of the opportunity for a different outcome to discussions about Mrs A’s early retirement. The Ombudsman also recommended that the Health Board should remind the clinicians involved in Mrs A’s care of the importance of discussing potentially relevant medication interactions with patients at the earliest possible opportunity and clearly documenting the consideration of medication interactions in patient notes.

Ms A complained that Aneurin Bevan University Health Board (“the Health Board”) did not follow appropriate guidelines when making its decision not to progress a retrospective Continuing Health Care (“CHC”) claim to an Independent Review Panel. The Ombudsman was concerned that whilst the Health Board had loosely followed the requirements of the CHC National Framework, the Independent Chair’s rationale for not moving to an Independent Review Panel was generic, and did not specifically address concerns raised. The Independent Chair did not address a legitimate concern regarding the date of CHC eligibility. The Ombudsman sought and gained the Health Board’s agreement to, within 1 month, refer the case to a different Independent Chair to reconsider whether an Independent Review Panel is warranted, with the new Independent Chair addressing the specific point about the date of CHC eligibility. The Ombudsman also gained agreement for the Health Board to confirm that all future Independent Chair decisions will be accompanied with case specific rationale, and that evidence of this process would be provided within 2 months.

Mrs A complained that the Housing Association had failed to carry out maintenance on the correct part of the boundary between her property and the neighbouring Housing Association property which caused damage to her fence. Mrs A complained that some of the maintenance that had been carried out caused damage to her boundary and subsequently a lack of security at her property. The Ombudsman found that the Housing Association had not clearly understood and addressed Mrs A’s concerns and this caused additional frustration and uncertainty for Mrs A. The Ombudsman decided to settle the complaint without a formal investigation. The Ombudsman sought and gained the Housing Associations agreement to a site meeting to review the boundary between the properties by 30 March, provide a written report detailing maintenance work agreed within one week of the site meeting and complete the agreed works within one month of the report.

Mr O complained on behalf of his wife, Mrs O, about care provided to her by Betsi Cadwaladr University Health Board (“the Health Board”). The investigation considered whether the Health Board failed to provide appropriate dressings for a wound to Mrs O’s left buttock between February and August 2024 and whether it failed to provide adequate assistance for Mrs O to safely access the taxi rank after she left Ysbyty Gwynedd Emergency Department (“the ED”) on 27 June 2024. The investigation found that on 16 March Mrs O had requested continuation of the previous wound care regime established before she moved to the Health Board’s area, but the Health Board’s clinicians recommended a change of approach without providing an adequate rationale. It was not until 17 July that district nurses recognised that the previous regime was more appropriate for Mrs O’s needs. The investigation found that the available evidence did not support that sufficient dressings were provided by the Health Board to meet Mrs O’s wound care needs prior to 17 July. While the types of dressings recommended by the Health Board’s clinicians were not inappropriate generally, there was a failure to recognise that they were not suitable for Mrs O, taking into account that her method of mobilising and patterns of activity caused her to need frequent daily dressing changes. The investigation found that, had the Health Board appropriately considered and addressed Mrs O’s needs sooner, the need for Mr and Mrs O to purchase dressings privately could have been avoided or at least reduced. This was an injustice to them. Accordingly, this part of the complaint was upheld. The Ombudsman made a number of recommendations including, an apology and a financial redress payment of £1000 to Mr and Mrs O for injustices caused by these failings. She also recommended service improvement actions, including a reminder of expected care standards for relevant clinicians and a review of procedures for managing patients who move

Mr S complained about the care and treatment provided to him by Swansea Bay University Health Board and specifically that it unnecessarily delayed his treatment for cancer and exceeded the 62 day suspected cancer to treatment pathway. The Ombudsman found that the Health Board had not fully responded to Mr S’s complaint. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to provide confirmation, within 5 days, to Mr S that his complaint about events that it had not addressed would be fully investigated with in accordance with The National Health Service (Concerns, Complaints and Redress Arrangements) (Wales) Regulations 2011.

Ms A complained that Hywel Dda University Health Board failed to respond to the complaint she submitted in May 2025. The Ombudsman found that the Health Board failed to provide Ms A with a final complaint response. The Ombudsman said this caused uncertainty and frustration for Ms A and decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to, within 7 weeks, issue the final complaint response, apologise and provide an explanation for the delay, and offer £150 redress payment in recognition of the delays.

Mr B complained that Newydd Housing Association had failed to properly address his concerns about his boiler. The Ombudsman found that the Association had failed to log Mr B’s concerns as a formal complaint and communication with Mr B had falled short of expected standards. She said that this caused frustration and uncertainty to Mr B. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Association’s agreements to write to Mr B with an apology for the failure to log his concerns as a formal complaint, provide a further apology for the lack of clear communication, confirm the timetable for repairs to be undertaken, and issue a complaint response within 2 weeks.

Mrs A’s complaint centred on whether her gallstone management by the GP Practice had been appropriate, given her blood test results in 2021, 2023 and 2025. Mrs A was admitted to the local hospital with pancreatitis and gallstones via the Emergency Department on 26 January 2025. The Ombudsman’s investigation found no link between Mrs A’s previous blood test results in 2021 and 2023 and her subsequent gallstones. The Ombudsman found some shortcomings in Mrs A’s clinical management and documentation at a June 2023 GP consultation. However, on balance, it was concluded that even if the GPs had followed the relevant liver function pathway, Mrs A’s gallstones would not have been identified earlier. The GP Practice’s clinical management and care in relation to Mrs A’s 21 January 2025 blood test results was also found to be reasonable and appropriate. The GP Practice was invited to consider the points of learning in relation to Mrs A’s June 2023 consultation.

Mr B complained about the way Cardiff Council responded to an application for rehousing he made in November 2024. The Ombudsman found deficiencies in the standard of record keeping by the Council. This included inconsistent documentation of telephone conversations and the reasons for decisions made relating to Mr B’s application. This caused uncertainty and frustration to Mr B. She decided to settle the complaint without investigation. The Ombudsman sought and gained the Council’s agreement to, with 1 month, apologise to Mr B for these failings and to remind relevant officers of the importance of maintaining accurate records when dealing with housing allocations.

Mr J complained that a joint risk assessment undertaken by the Council and the Health Board and provided to a Supported Housing Provider (SHP) was missing key information about his son’s needs. This led to him being placed in what Mr J believed to be an unsuitable placement. Mr J also complained that the Council was not willing to carry out its own investigation into his concerns about the risk assessment when a proposed joint investigation with the Health Board did not progress. The investigation against the Council identified failings around documentation and how aspects of the care co-ordinator role had been carried out. However, the Ombudsman concluded that, prior to the placement, the SHP was provided with sufficient key information about the needs of Mr J’s son by the Health Board who was jointly involved in commissioning the placement. In relation to the Council and the Health Board, this part of Mr J’s complaint was not upheld. The Ombudsman found that an opportunity for the Council to identify and learn lessons from Mr J’s complaint was missed by its decision not to carry out its own investigation. The injustice for Mr J was that he had to complain further in order to obtain answers. This part of Mr J’s complaint was upheld. The recommendations to the Council included apologising to Mr J and carrying out an audit across the Community Mental Health Teams in order to satisfy itself that the requirements of the care co-ordinator role, as well as wider processes and systems, are being met. As part of the audit process the Council was asked to engage with the Health Board as appropriate. The Health Board was invited to engage with the Council around the audit recommendation set out above, as this would also provide an opportunity to ensure that any wider points of learning around systems and processes in relation to jointly commissioned care are maximised.

Mrs A complained that following her complaint to Vale of Glamorgan Council it failed to provide a Stage 2 complaint response. The Ombudsman found that whilst the complaint was escalated to Stage 2 procedure, Mrs Ahad not received the final Stage 2 response. The Ombudsman said this caused uncertainty and frustration for Mrs A and decided to settle the complaint without an investigation. The Ombudsman sought and gained the Council’s agreement to, within 6 weeks, issue the final Stage 2 complaint response, apologise and provide an explanation for the delay.

Mr J complained that a joint risk assessment undertaken by the Council and the Health Board and provided to a Supported Housing Provider (SHP) was missing key information about his son’s needs. This led to him being placed in what Mr J believed to be an unsuitable placement. Mr J also complained that the Council was not willing to carry out its own investigation into his concerns about the risk assessment when a proposed joint investigation with the Health Board did not progress. The investigation against the Council identified failings around documentation and how aspects of the care co-ordinator role had been carried out. However, the Ombudsman concluded that, prior to the placement, the SHP was provided with sufficient key information about the needs of Mr J’s son by the Health Board who was jointly involved in commissioning the placement. In relation to the Council and the Health Board, this part of Mr J’s complaint was not upheld. The Ombudsman found that an opportunity for the Council to identify and learn lessons from Mr J’s complaint was missed by its decision not to carry out its own investigation. The injustice for Mr J was that he had to complain further in order to obtain answers. This part of Mr J’s complaint was upheld. The recommendations to the Council included apologising to Mr J and carrying out an audit across the Community Mental Health Teams in order to satisfy itself that the requirements of the care co-ordinator role, as well as wider processes and systems, are being met. As part of the audit process the Council was asked to engage with the Health Board as appropriate. The Health Board was invited to engage with the Council around the audit recommendation set out above, as this would also provide an opportunity to ensure that any wider points of learning around systems and processes in relation to jointly commissioned care are maximised.