PSOW Individual Decisions

Ms M complained that Cwm Taf Morgannwg University Health Board failed to respond to a complaint she raised on 6 June 2024. The Ombudsman found that there had been a significant delay by the Health Board in concluding the complaint. This caused additional frustration and inconvenience for Ms M. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to issue its complaint response within 4 weeks. It should include an apology and explanation for the delay and an offer of £100 for the inconvenience caused.

Mrs B complained about the care and treatment provided by the Health Board for her mental health and neurological condition. In addition, Mrs B raised concerns about not receiving responses from the relevant team involved in her care. The Ombudsman found that although the Health Board had provided a response to Mrs B, she remained unclear as to some aspects of the care and treatment available to her. The Ombudsman considered that Mrs B had not had a full response to her complaint and contacted the Health Board, which agreed to undertake the following actions to resolve the complaint and as an alternative to a formal investigation. The Ombudsman sought and gained the Health Board’s agreement to provide Mrs B with a full response within 4 weeks. The Health Board agreed to clarify, in its response, the status of any referrals made to services outside of the Health Board area and confirm the status of any upcoming appointments.

Mr A complained that he had to write 3 letters to Cwm Taf Morgannwg University Health Board before it responded to his concerns about his son’s healthcare in prison. Mr A was dissatisfied with the Health Board’s complaint response, the handling of his complaint, and the provision of information. Mr A said that his son’s healthcare issues remained undiagnosed and untreated. The Ombudsman decided Mr A’s son appeared to have been given access to relevant healthcare, and had been referred for further investigations with specialist services where necessary. There was no evidence of significant personal injustice in relation to this. However, the Ombudsman was concerned about the handling of the complaint, including delays and miscommunication, that had resulted in Mr A being denied the opportunity to discuss his concerns. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement within 1 month, to offer Mr A an apology and £150 redress for the time and trouble taken in trying to resolve his concerns. The Health Board also agreed to provide Mr A with any outstanding information that he was entitled to, and an explanation and apology for the miscommunication and the lack of response to his initial concerns.

Mr X complained about the standard of treatment provided to him by Cwm Taf Morgannwg University Health Board in relation to his orthopaedic pain. Specifically, the Ombudsman’s investigation considered whether the tests and investigations carried out into his left hip and foot pain during hospital admissions in July and August 2022 were reasonable and appropriate. The Ombudsman found that the tests and investigations carried out during Mr X’s hospital admissions in July and August were reasonable and appropriate. The Ombudsman noted that, on assessment, no neurology was found at these admissions and the eventual neurological diagnoses were not indicated. It would have been good clinical practice for an earlier MRI to have been done, but this would not have reached the diagnosis earlier or altered the prognosis for Mr X. The Ombudsman did not uphold the complaint.

Mrs X complained that the Practice had failed to respond to her email dated 24 November in respect of her concerns regarding her herniated disc diagnosis. The Ombudsman concluded that the Practice had failed to respond to the email. The Ombudsman said this caused uncertainty, frustration, and inconvenience to Mrs X. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Practice’s agreement to apologise for the oversight, delay and inconvenience caused and to provide a response to the relevant email within 3 weeks.

Ms X complained that the Health Board continued to send her appointment letters in the name of a member of staff who she had complained about previously. Receiving these letters was causing unnecessary distress. The Ombudsman decided that although the Health Board had made some changes to its processes there was still a risk that Ms X could receive letters in the name of the staff member in future. The Ombudsman approached the Health Board and asked them to consider what further action could be taken. The Health Board removed the staff member’s name from the relevant electronic system, thereby removing the risk. The Ombudsman considered that the action was reasonable and settled the complaint without an investigation.

Miss C complained on behalf of her son, B, about the treatment he received for obsessive compulsive disorder (“OCD” – a mental health condition where a person has obsessive thoughts and compulsive behaviours). The investigation considered whether the decision not to prescribe B with medication to treat his OCD in September 2022, was clinically appropriate. The investigation found that the decision not to prescribe B medication was in line with the relevant guidance and was therefore clinically appropriate. The Ombudsman did not uphold this complaint.

Mr A complained about issues relating to his ongoingwait for knee surgery. Instead of formally investigating and responding to MrA’s complaint, the Health Board sought to informally resolve the matter. The Ombudsman was concerned that the Health Board didnot resolve Mr A’s complaint and had not formally investigated and responded tohis concerns either. The Ombudsman decided to settle the complaint without an investigation. She obtained the Health Board’s agreement to investigate and formally respond to Mr A’s concerns under the Putting Things Right arrangements, to apologise for failing to offer to do so before now and to offer him a time and trouble payment of £125. The Health Board agreed to undertake these actions within 30 working days.

Ms A complained about care provided on behalf of Cwm Taf Morgannwg University Health Board. Ms A said that a number of fully trained regular carers had left without notice, the standard of care had declined and she had been left without care on around 10 occasions. Ms A had made a formal complaint but had not received a response. The Ombudsman concluded that the Health Board was making appropriate enquiries to identify an alternative care provider. However, it had failed to issue a complaint response to Ms A. She said this caused frustration and uncertainty to Ms A. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to provide a complaint response to Ms A within one month.

Mrs A complained about the care and management she received at one of the Cwm Taf Morgannwg University Health Board’s (“the Health Board”) hospitals in January 2022. She had complained to the Health Board in May 2024, but it had declined to investigate her complaint because it said her complaint was out of time. This was despite her providing mitigating factors for her late complaint. The Ombudsman noted that under the relevant complaint regulations the Health Board can reject a complaint if not brought within 12 months of a person being aware of the problem. However, in doing so it must provide an explanation/rationale for not investigating. This did not happen in Mrs A’s case. In addition, it did not include the Ombudsman’s contact details in its letter to Mrs A, should she be unhappy with the Health Board’s decision. As a resolution the Health Board agreed within 4 weeks to: a) Write to Mrs A setting out its consideration of her extenuating evidence and its rationale for not taking these into account and investigating her late complaint. b) Apologise to Mrs A for not providing a rationale for the rejection of her complaint. c) Undertake a review of its rejection decision letter template so that explanations/rationale are included for any future rejections and that the Public Services Ombudsman for Wales’s contact details are added.

Mr X complained that Cwm Taf Morgannwg University Health Board transferred his endocrinology care to another health board, without any notice or explanation provided. Mr X complained to the Health Board over a period of months, but did not receive a response. The Ombudsman decided that despite multiple requests by Mr X and an earlier proposal by the Ombudsman, the Health Board failed to respond to his complaint in line with Putting Things Right, or provide him with a written explanation for its decision to transfer his care. There was also a delay in providing his records. The Ombudsman said that this caused delays and frustration for Mr X. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement within 6 weeks to apologise to Mr X, offer him £250 redress for the delays and failure to provide a complaint response and to respond to his concerns in line with Putting Things Right. It also agreed to remind all staff involved in the case of the Violence and Aggression Incident reporting requirements, including timescales, in line with the Health Board’s policies and procedures.

Mrs A complained about the care and treatment her late husband received from Cwm Taf Morgannwg University Health Board (“the Health Board “). The Ombudsman found that the Health Board’s response to Mrs A’s complaint was detailed and acknowledged its failings. However, the Health Board could not locate the audio recording of a follow-up meeting held with Mrs A. The Ombudsman could therefore not determine whether Mrs A had raised concerns in the meeting about her husband’s fractured vertebrae, which had been discovered after the Health Board’s complaint response was received. The Ombudsman sought and gained the Health Board’s agreement to apologise to Mrs A for failing to locate the audio recording of the meeting and to contact Mrs A to establish a way forward in responding to her additional concerns about her husband’s vertebrae, within 4 weeks.

Mrs A complained about the appropriateness of the treatment she received for her presenting symptoms by the Clinical Musculoskeletal Assessment and Treatment Service (“CMATS”)/physiotherapy. She referred to the fact that an MRI scan had not been undertaken and she questioned whether sufficient investigations were undertaken when she attended Prince Charles Hospital (“the First Hospital”) and Royal Glamorgan Hospital (“the Second Hospital”) between 17 May and 12 July 2021. Broadly, the Ombudsman considered that Mrs A had been treated appropriately by the Physiotherapist for her presenting symptoms. While the Ombudsman identified areas where communication could have been more effective than it was, the Physiotherapist’s decision that Mrs A did not require further investigation or an urgent MRI was not wrong. When Mrs A attended an emergency orthopaedic clinic on 17 May, she had no symptoms that would have been of urgent clinical concern. In reviewing Mrs A’s Emergency Department attendances, the Ombudsman’s investigation found that there were no clinical concerns that would have prompted the need for an urgent MRI scan. In terms of Mrs A’s hospital attendances between 17 May and 12 July, based on her clinical symptoms and presentation, the evidence pointed to sufficient investigations being undertaken. Mrs A’s complaints were not upheld.

Ms A complained about the care and treatment her late sister received from Cwm Taf Morgannwg University Health Board (“the Health Board”), when she was in hospital prior to her sad death. The Ombudsman decided that the Health Board had not informed Ms A, in a timely manner, that it was unable to deal with all of the questions raised in her complaint as some needed to be directed to another Health Board. 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 write to Ms A to apologise for the error in not informing her sooner that it could not deal with all her concerns and make a redress payment in the sum of £150, in recognition of the delay this caused her in getting answers.

Mr X complained that Cwm Taf Morgannwg University Health Board failed to respond to his complaint and, instead, arranged a meeting with him without providing further details. The Ombudsman found that the Health Board had attempted to arrange a meeting with Mr X. However, due to staff sickness and difficulties in arranging a mutually convenient time, Mr X’s complaint remained unresolved, this caused additional frustration and uncertainty for him. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to, within 4 weeks, provide Mr X with a formal complaint response, along with a written apology and explanation for the delay in providing the complaint response.

Miss D complained that Cwm Taf Morgannwg University Health Board had ignored her, failed to communicate and failed to respond to her complaint. The Ombudsman found that Miss D had complained to the Health Board but had not received a response within a reasonable timeframe. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to apologise to Miss D and explain why this happened, offer her a redress payment of £75 in recognition of the time and trouble to complain and issue its complaint response within 30 working days.

Mr A complained that he was forced to take out a loan to undergo a private knee replacement after being told by the Cwm Taf Morgannwg University Health Board (‘the Health Board’) that there was a 2-3 year wait, and that priority under the terms of the Armed Forces Covenant did not apply. Mr A advises that he originally complained in November 2023, and has yet to receive a response. The Ombudsman recognised that there had been a significant delay in the Health Board providing a full response. The Ombudsman sought and gained the Health Board’s agreement to within 1 month, provide Mr A with a full response to his concerns.

Ms C complained that Cwm Taf Morgannwg University Health Board failed to provide a response to her complaint, which she made to it in May 2023. The Ombudsman found that whilst the Health Board had provided updates, it had failed to issue a complaint response. She said this caused frustration to Ms C. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to issue a complaint response to Ms C within 3 months, to include an apology for the identified failure and to offer to pay Ms C £250 for her time and trouble in making her complaint to the Ombudsman.

Mrs X complained that Cwm Taf Morgannwg University Health Board failed to respond to her letter sent to it in July 2024 regarding her ongoing treatment for her Functional neurologic disorder. The Ombudsman decided that the Health Board had failed to respond to the concerns raised. The Ombudsman said this caused uncertainty, frustration, and inconvenience to Mrs X. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to issue a service response (within 5 weeks) to address Mrs X concerns. The letter should also offer an apology for the delay and oversight in not responding sooner.

Miss A complained that Cwm Taf Morgannwg University Health Board failed to respond to a complaint she raised about how she was treated by a Community Practice Nurse. The Ombudsman found there had been a delay responding to the complaint as there was confusion as to whether it would need to be investigated by Human Resources. This caused additional frustration and uncertainty for Miss A. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Boards agreement to write to Miss A, within one week, with an apology for the delay and an explanation of how her complaint was dealt with.

Miss T complained that Cwm Taf Morgannwg University Health Board has not provided the necessary treatment to deal with her chronic pain. The Ombudsman found that whilst the Health Board had responded to Miss T’s concerns informally, it failed to correctly escalate her complaint in accordance with its complaints process when Miss T remained dissatisfied. She said this caused frustration and uncertainty to Miss T. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to write to Miss T with an apology for the identified failure and to issue a formal complaint response within 6 calendar weeks.

Mrs F complained that Cwm Taf Morgannwg University Health Board failed to issue a response to her follow up letter which she made to it following receipt of the Health Board’s complaint response in June 2024. The Ombudsman found that the Health Board had failed to issue a response to Mrs F’s further letter. She said that this caused frustration and uncertainty to Mrs F. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to issue a further response to Mrs F, to include a further apology for the delay within 4 calendar weeks.

Miss B complained that Cwm Taf Morgannwg University Health Board had failed to respond to her complaint, which made her feel ignored. The Ombudsman found that Miss B had complained to the Health Board but had not received a response within a reasonable timeframe. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to issue its complaint response, an apology for the delay and inconvenience caused, and a redress payment of £150 (within 6 weeks) in recognition of the delays and need to approach the Ombudsman.

Mr B complained about the care and treatment his partner received when she was an in-patient at the Royal Glamorgan Hospital, in particular, whether she should have been moved to the Intensive Care Unit (“ICU”) sooner than she was. The Ombudsman decided that whilst the Health Board had responded to Mr B’s complaint, it had not provided an explanation of the clinical reasoning for not admitting his partner to the ICU sooner. 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 provide a further response to Mr B, outlining the clinical reasoning for his partner not being admitted to the ICU earlier.

Ms C complained about the care and treatment provided to Mr B by the Health Board’s mental health services between 6 July and 7November 2022. Specifically, the investigation considered whether the care and treatment provided to Mr B in the community between 6 July and 22 September 2022 was clinically appropriate. It also considered whether the care and treatment provided to Mr B during his admission to hospital, including the arrangements for his discharge, between 23 September and 7 November 2022 was clinically appropriate. The Ombudsman found that Mr B’s care and treatment in the community between 6 July and 22 September was clinically appropriate. Mr B received appropriate assessments and input. There was no evidence that a lack of care and treatment in the community setting resulted in Mr B’s deterioration or his admission to hospital on 23 August. This complaint was not upheld. The investigation found that, following the hospital admission, appropriate care and treatment had been provided in respect of physical assessments, occupational therapy and meeting Mr B’s basic needs. However, it was not clear what arrangements were made for Mr B to have a follow-up a Magnetic Resonance Imaging scan (“MRI”- the use of strong magnetic fields and radio waves to produce detailed images of the inside of the body) that was indicated as being needed after discharge. Cognitive test results for Mr B during admission were also not appropriately followed up. The evidence for Mr B’s diagnosis was lacking, and a rationale for the diagnosis was not clearly stated either. Other possibilities were not appropriately explored. This called into question the rationale put forward for Mr B’s discharge. The documentation available was inadequate to demonstrate how safety was to be maintained within the temporary home upon discharge. Ms C was not informed of where Mr B was to be discharged, and he did not receive the input of a care co-ordinator to facilitate the transition. This complaint w