PSOW Individual Decisions

Mrs X complained that Cardiff and Vale University Health Board failed to publish specific public guidance about the best care pathway and treatment approach for children with Cystic Fibrosis suffering with significant urinary incontinence. Mrs X said her child had been left to suffer for 18 months without a referral for treatment. The Ombudsman concluded that the Health Board had failed to provide an appointment for Mrs X’s daughter within a reasonable amount of time and it lacked specific published pathway guidance. The Ombudsman said this caused uncertainty, frustration, and inconvenience to Mrs X and her child. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to contact Mrs X to confirm an appointment with the Biofeedback Clinic undertaken by the Continence Specialist Nurses (within 3 weeks). It should also consider publishing guidance about the best pathway and treatment approach for a child with urinary incontinence.

Mr A’s complaint centred on the way that a mental assessment had been carried out by social workers in the Community Mental Health Team. Mr A was also unhappy that he had not had a response to the emails that he had sent after receiving the Health Board’s complaint response. Mr A referred to the fact that the Health Board had offered a a local resolution meeting but noted that it would not be recorded. The Health Board agreed to respond to Mr A’s post complaint response queries and to let him know whether it had anything further to add. It also agreed to confirm the Health Board’s process for recording local resolution meetings and to offer him the opportunity to make his own recording of the meeting should he decide to take up the offer of a meeting.

Mrs A complained about care and treatment provided by Cardiff and Vale University Health Board in relation to facial pain she has been experiencing. She said that Health Board’s response was overly formal and difficult to understand. The Ombudsman said that the Health Board should take steps to ensure that Mrs A understood its response. The Ombudsman sought and gained the Health Board’s agreement to within 1 month, contact Mrs A to discuss whether there are any reasonable adjustments that would help her understanding of the final response, and offer to meet with her to explain the letter and aid her understanding of it.

Mr A complained that whilst awaiting an inpatient procedure under the care of Cardiff and Vale University Health Board (“the Health Board”), he was unnecessarily kept nil by mouth. Mr A believes that this contributed to him having his first seizure and that he lost his driving licence as a result. Mr A said that the Health Board’s responses to his complaint were dishonest. The Ombudsman decided that there were some inconsistencies with the Health Board’s complaint responses, and the information documented in Mr A’s medical records. She said that this caused delays and frustration for Mr A. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement within to, within 1 month, apologise to Mr A that he has had to contact the Ombudsman. To provide a further response to Mr A, clarifying the issues raised in relation to his fluid intake and monitoring, on the day of his procedure. To apologise for any issues identified in the care provided, and for any errors and contradictions identified in the Health Board’s previous responses. The Health Board also agreed to identify any relevant learning points and action.

Mr A complained that the Health Board had failed to provide the injections required to treat his dystonia (a neurological condition which causes uncontrolled muscle contractions). He said that this resulted in him having to seek treatment privately during this time. The Health Board accepted that there had been a period of time when it was unable to provide any service to dystonia patients due to specific staffing issues. The service was now operational and appointments had been arranged. The Health Board agreed to reimburse the cost of Mr A’s injections that fell within the period when it had been unable to provide any service.

Mr A complained about the care and treatment provided to his wife, Mrs A, for ongoing head and neck pain. Specifically, the investigation considered whether Mrs A’s occipital neuralgia (a condition where the nerves that run through the scalp are injured or inflamed) should have been identified and treatment offered following her attendances at hospital in 2018 and 2020. The investigation also considered whether it would have been appropriate to offer nerve blocks to Mrs A in September 2021. The investigation found that Mrs A underwent an appropriate assessment and investigation when she attended hospital in 2018 and that the diagnosis made at the time was reasonable. It also found that whilst there was a delay in Mrs A receiving nerve blocks, given the complexity of her condition and response to treatment, this was unlikely to have had a significant impact on her eventual outcome. These parts of Mr A’s complaint were not upheld. In respect of Mrs A’s attendance at hospital in 2020, the investigation found that there were missed opportunities to identify that Mrs A was suffering with occipital neuralgia. This part of Mr A’s complaint was upheld. The Health Board agreed to apologise to Mr and Mrs A for failing to identify Mrs A’s occipital neuralgia when she attended hospital in 2020. It agreed to offer Mr A a payment of £1,500 in recognition of this failure and to ensure that the clinicians who treated Mrs A on this occasion are familiar with the symptoms of occipital neuralgia and its management.

Miss G complained that she had been waiting for five years to undergo surgery, but the Health Board had told her that she was now not fit for surgery. Miss G said that the Health Board had failed to provide her with a proper explanation as to why she was not fit for surgery. Miss G also complained that when she had attended appointments her records either could not be located or contained incorrect information. The Health Board said that Miss G had been offered an appointment with a consultant to discuss her treatment options and that there was no evidence of incorrect information in her records. In its complaint response to Miss G the Health Board did not explain how or when the decision was made that she was not fit for surgery. It also did not fully explain how it had reached the conclusion that her records did not contain incorrect information. The Health Board agreed that, within 2 weeks, it would write to Miss G explaining the reasons why she is not fit for surgery and when/how this was discovered, along with a further explanation of its view regarding her medical records.

Mr C complained about the care and treatment provided to him by Cardiff and Vale University Health Board (“the Health Board”). The investigation considered whether the care and treatment Mr C received between 17 May and 27 September 2022 from the Health Board’s Oral and Maxillofacial Surgery Team was appropriate and he was diagnosed correctly. The investigation found that the care and treatment Mr C received from the Health Board’s Oral and Maxillofacial Surgery Team between 17 May and 27 September was appropriate and reasonable and that the working diagnosis given to Mr C was also appropriate. The Ombudsman did not uphold this complaint.

Ms A complained about the care and treatment she received from Cardiff and Vale University Health Board (“the Health Board”), when she presented at the Emergency Department with lower back pain and painful urination in September 2023. She said that she went on to be diagnosed with cysts on her ovaries, in January 2024, requiring emergency surgery. The Ombudsman decided that the complaint response from the Health Board referred to incorrect information regarding what types of cysts Ms A had. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement that, within 6 weeks, it would send a further response to Ms A referring to the correct information.

Mrs H complained that Cardiff and Vale University Health Board had failed to provide her with any clarity about her treatment plan and that there had been a lack of communication between the departments involved in her care. The Ombudsman found that the Health Board had considered Mrs H’s concerns by way of an early resolution, this had taken 6 months and Mrs H was then incorrectly informed to contact the Ombudsman if her concerns had not been resolved. The Ombudsman decided the Health Board had failed to follow its complaints process appropriately and this had caused frustration and inconvenience for Mrs H. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to apologise to Mrs H and pay her £50 redress for its failure to follow the complaints process. The Health Board also agreed to issue a PTR response within 30 working days.

Ms A complained that Cardiff and Vale University Health Board failed to respond to a complaint she raised concerning waiting times for surgery. The Ombudsman found that the Health Board discussed its findings over the telephone but failed to issue a written response to Ms A. This caused uncertainty and frustration for Ms A. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to issue a written response within 2 weeks.

Miss A complained that there were missed opportunities to make an earlier referral and/or undertake investigations by Cardiff and Vale University Health Board (“the Health Board”) in respect of her pregnancy losses between April 2021 and September 2022. She also complained that there was maladministration in the handling her complaint and in particular, that delays impacted negatively on her potential treatment options. The investigation found that Miss A and her partner were referred to the Wales Fertility Institute shortly after they met all of the eligibility criteria. It also found that karyotype (a process used to examine chromosomes) testing was considered at the appropriate time and that it was reasonable of the Health Board not to recommend a hysteroscopy. The investigation found that there was no clinical indication for Miss A to have been prescribed folic acid before she was referred to the Wales Fertility Institute and that the Health Board took reasonable steps to inform Miss A of the results of genetic testing following her fifth pregnancy loss. These parts of Miss A’s complaint were not upheld. The investigation found that the Health Board’s failure to send tissue from Miss A’s fourth pregnancy loss for genetic testing was a source of lasting uncertainty to her, which was an injustice. It also found that there was a missed opportunity to resolve aspects of Miss A’s complaint sooner. These parts of Miss A’s complaint were upheld. The Health Board agreed to apologise to Miss A for the failings identified in the investigation. It also agreed to remind staff who investigate complaints of the potential options to provide an early resolution to aspects of complaints.

Mrs A complained about the standard of care she received at the University Hospital of Wales (“the Hospital”). Specifically, she complained that a pulmonary embolism (“PE”) should have been diagnosed before she was discharged from the Hospital. This was diagnosed 4 days later at a different hospital. The Ombudsman did not uphold the complaint. We found that the clinical management and investigation of Mrs A’s presenting symptoms at the Hospital was appropriate. The clinical findings did not indicate the presence of PE at that point. The decision to discharge Mrs A from the Hospital was reasonable.

Mr D complained about the care and treatment his wife had received from the Practice. He complained about communication including that she had attended an appointment which was cancelled without prior warning. He also complained that he had requested copies of his wife’s records on 13 March 2024, in order to inform a formal complaint about her care, and these were not provided despite him supplying the required consent from his wife. Mr D complained that his wife had not received permanent fillings despite multiple appointments and instead said she had been lectured on dental hygiene. The Ombudsman found that Mr D had provided the required consent for his wife’s records to be released to him but the Practice had not actioned this. Mr D had therefore been unable to submit a formal complaint of his concerns. The Ombudsman also found Mr D had informed the Practice that his preferred method of communication was email. The Practice agreed to, within 4 weeks, issue Mr D with an apology and explanation about why he was not provided with his wife’s dental records. It also agreed to provide a copy of the records to enable him to submit a formal complaint. The Practice also agreed to confirm to Mr D that the system had been updated with his preferred method of communication. The Ombudsman considered these actions were reasonable and the complaint was closed on this basis.

Mrs A complained about the standard of care and treatment Cardiff and Vale University Health Board (“the Health Board”) provided to her mother, Mrs B, prior to her death in hospital. The Ombudsman decided that the Health Board had provided a limited final response to Mrs A’s concerns, which did not reflect what had been discussed in a meeting held between Mrs A and the Health Board. 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, provide a full response to Mrs A to acknowledge what went wrong and if relevant, a written apology, as well as details of any learning and improvement taken from the complaint.

Ms Y complained about the care and treatment she received from Cardiff and Vale University Health Board in 2023. She specifically complained that there was a failure to provide adequate support during a consultation on 30 January and when she contacted the Community Mental Health Team on 31 January. She complained that during her subsequent hospital admission she was inappropriately removed from section 2 of the Mental Health Act 1983 (legislation which covers the assessment, treatment and rights of people with a mental health disorder) and there was a failure to undertake appropriate discharge planning. She also complained that, following discharge from hospital, she did not receive appropriate care and support. The investigation found that the consultation on 30 January and assessment on 31 January were both clinically reasonable. It was also found that, while Ms Y was an inpatient in hospital, it was appropriate to remove her from section 2 of the Mental Health Act 1983 and appropriate discharge planning took place. Finally, the investigation found that appropriate support was provided to Ms Y following her discharge from hospital. The complaints were not upheld.

Mx A complained that the Health Board had repeatedly not sent their ADHD documentation to the relevant department. The Health Board agreed to write to Mx A to confirm the date that the ADHD diagnosis documentation had been received by the relevant department and to provide an update on Mx A’s management and care.

Dr A complained about the Health Board’s decision not to offer financial redress to his mother, Mrs B under the Redress Scheme contained within The National Health Service (Concerns, Complaints and Redress Arrangements) (Wales) Regulations 2011 (“the Regulations). Dr A said that the Health Board had not completed an up-to-date assessment of Mrs B’s disability, that no evidence had been provided to support that the redress amount would exceed £25,000 and that Mrs B’s views had not been sought and considered. The Health Board agreed to the following: a) As per Regulation 32 of The Regulations, legal advice, without charge (to the limit of £1,600 plus VAT) shall be available to Dr A to consider the Health Board’s refusal to make an offer of financial redress under the Redress Scheme. The Health Board agreed to provide Dr A with a list of Solicitors and the necessary information around funding within 14 days. b) Following Dr A obtaining legal advice (if he so chooses), the Health Board will give further consideration (as per Regulation 29(3)) to making an offer of settlement outside of the provisions of the Regulations. c) The Health Board shall ensure it advises all complainants in writing that legal advice can be sought free of charge (under Regulation 32) if it makes the decision not to make an offer of financial redress under the Regulations.

Mrs C complained on behalf of her husband, Mr A, about the neurological care and treatment he received from Cardiff and Vale University Health Board between March and June 2021. The following matters were investigated: a) Whether Mr A’s neurological treatment from March to June 2021 was appropriate. Specifically: · Whether more could have been done to avoid infection. · Whether his external ventricular drainage shunt (“EVD” – a temporary measure method of draining fluid from in and around the brain and spinal cord) was changed sufficiently regularly. · Whether a ventriculoperitoneal shunt (“VP” – a small plastic tube to help drain extra fluid from in and around the brain and spinal cord) should have been considered. · If Von Willebrand disorder (an inherited condition where the blood does not clot properly) should have been considered. b) Whether Mr A was well enough to be transferred to a different hospital on 28 June 2021. The investigation found that the care and treatment provided to Mr A by the Health Board between March and June 2021 was clinically appropriate, as was the decision to transfer him to a different hospital on 28 June 2021. The Ombudsman did not uphold the complaints.

The Ombudsman found that overall, the care and treatment provided to Mr B at the First Hospital between 3 and 8 May 2022 was appropriate. The Ombudsman did not uphold complaints a) to c). The diagnosis and management of Mr B’s bowel obstruction was also considered to be reasonable and appropriate during that period. However, it was not considered appropriate to send Mr B home at 01:00 on 4 May following initial consideration of his investigative scan, with instructions to return to the First Hospital at 10:00 for further review. There was no indication of clinical harm to Mr B in this respect, but it was an injustice to him and to his family that appropriate care and consideration was not given to his circumstances at that time. To that limited extent only, this element of complaint d) was upheld I recommend that, within 1 month of the date of this report, the Health Board should: a) Apologise to Mr B’s family for the failures identified in this report b) Ensure that this report and its findings are shared with staff within the SAU unit, to enable staff reflection on the failing identified.

Mrs S complained about the poor care and treatment that was provided to her late mother by Cardiff and Vale University Health Board. She said she had raised her concerns with the Health Board but had not been provided with a PTR response. The Ombudsman found that whilst the Health Board had arranged a meeting with Mrs Sit had failed to follow its complaints process and issue a PTR response. The Ombudsman said this had caused frustration and uncertainty for Mrs S. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to apologise to Mrs Sand pay her £75 redress for its failure to follow the complaints process. The Health Board also agreed to clarify the outstanding concerns with Mrs Swithin 20 working days and following this, issue a PTR response within 30 working days.

Mr C complained about the care he received from the Practice. Mr C said that the Practice failed to discuss his treatment with him in detail or tell him that the person who would carry out the treatment would be a dental therapist, rather than a dentist. Mr C also complained that the Dental Therapist used amalgam (a mixture of metals) in the filling, to which he did not consent, and that he was unhappy with the quality of the work she performed. The Ombudsman found that Mr C had received a response to his complaint from the Dental Therapist who carried out his treatment. However, he had not received a formal response from the Practice. As a result, the Practice had not addressed Mr C’s complaint fully. The Practice agreed to provide a formal and final complaint response to Mr C, addressing his concern that treatment was performed without his informed consent. This would include whether it was the responsibility of the Dentist who prescribed his treatment or the Dental Therapist who carried it out, and whether appropriate informed consent was documented. It also agreed to offer Mr C an appointment for him to have his tooth reviewed. The Practice agreed to do this within 1 month of the Ombudsman’s decision.

Mr A complained about the care provided to him by the Health Board relating to his kidney condition. Specifically, the Ombudsman investigated whether: The result of an Albumin to Creatinine Ratio “ACR” test (a test to help identify kidney disease) in April 2017 (21.7mg/mmol) should have prompted an increase in Mr A’s enalapril medication. There should have been repeat yearly ACR tests in 2018 and 2019. The Ombudsman did not uphold the complaints. The investigation found that maintaining the same dose of enalapril medication following Mr A’s ACR test result in 2017 was reasonable, took account of other clinical factors and was not outside the range of normal clinical practice. In relation to repeating yearly ACR tests in 2018 and 2019, it was appropriate to monitor urine protein levels using a different (PCR) test. This was in line with accepted practice and did not result in any detriment to Mr A.

Ms C complained about the care and treatment she received from Cardiff and Vale University Health Board. Specifically, she complained about whether the delay between a large fibroid being confirmed and a hysterectomy being performed was acceptable, whether opportunities were missed to make an earlier diagnosis of endometrial cancer and whether the possibility of deep vein thromboses and pulmonary embolism should have been considered before February 2021. The investigation found that the delay in Ms C undergoing a hysterectomy was not acceptable, even considering unavoidable delays caused by COVID-19 restrictions. There were missed opportunities for Ms C to have undergone surgery before the introduction of COVID-19restrictions and rules relating to referral to treatment times were misapplied. Opportunities were mere missed to have diagnosed Ms C’s endometrial cancer earlier. The symptoms she was expiring meant that referrals for further treatment and investigation should have been made earlier than they were, and if they had she may well have been diagnosed with endometrial cancer up to 2years earlier than her eventual diagnosis. These parts of Ms C’s complaint were upheld. The investigation found that deep vein thromboses and pulmonary embolism should have been considered when Ms C attended hospital on 1 February2021. As this falls outside the time period specified in the complaint this part of Ms C’s complaint was partially upheld The Health Board agreed to apologise to Ms C. It also agreed to share the investigation report with relevant clinicians and to ensure that clinicians that treated Ms C were aware of symptoms that required further endometrial assessment. The Health Board also agreed to audit a sample of gynaecological cases to ensure that referral to treatment times have not been misapplied in other cases.

Ms A complained on behalf of her husband, Mr A, about the assessment and treatment provided by Cardiff and Vale Health Board (“the Health Board”) for a laceration to his left wrist when he attended the University Hospital of Wales (“the Hospital”) Emergency Department on 24 August 2022. The investigation found that Mr A did not receive appropriate treatment and assessment when he attended the Hospital. Accurate records were not kept of the treatment he received, and opportunities were missed for Mr A to be referred for more timely treatment of his injury. The use of a translation service was also not considered despite Mr A not speaking English as a first language. This complaint was therefore upheld. The Health Board agreed to apologise to Mr and Ms A. It also agreed to remind the clinician that treated Mr A of the importance of keeping accurate records and to ensure that she is familiar with both the Health Board’s guidelines on treating hand injuries and the Health Board’s Interpretation and Translation Service Policy. In addition, it agreed to develop a policy on referrals for treatment for patients that live outside the Health Board area and to conclude a review of its Interpretation and Translation Service Policy and ensure that all relevant staff are aware of it.