PSOW Individual Decisions

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 B complained that Rhondda Cynon Taf County Borough Council refused to escalate his complaint to Stage 2 of its corporate Complaints Procedure. The Ombudsman found that the Council had improperly refused to escalate Mr B’s concerns. 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 Council’s agreement to write to Mr B with an apology for the failure to escalate his complaint and issue a Stage 2 complaint response within 3 weeks.

Mr H complained about the quality of his daughter’s swimming lessons and a failure by Carmarthenshire County Council to respond to the complaint he made to it in October 2025. The Ombudsman found that the Council had acknowledged Mr H’s complaint in October 2025 and had failed to respond, which she said caused frustration to Mr H. The Ombudsman decided to settle the complaint without a formal investigation. The Ombudsman sought and gained the Council’s agreement to apologise to Mr H for failing to respond to his complaint, to explain to him why no response was issued, and to issue a Stage 2 complaint response within 4 weeks.

Mr B complained about the inpatient care and treatment his late father, Mr A, received at Ysbyty Glan Clwyd in 2024. The investigation focused on whether it was appropriate to stop Mr A’s long-term oxygen therapy (“LTOT” – supplemental oxygen usually given via a nasal tube from a portable machine) given the fact that he was on it at home. The investigation also considered whether there was a delay in escalating Mr A’s care on 11 February and whether a higher National Early Warning Score (“NEWS,” a clinical tool used to determine whether a patient’s care needs to be escalated) would have changed his management. The investigation found that even though Mr A was on LTOT, providing supplementary oxygen for 15 hours and not 24 hours was appropriate. The investigation concluded that stopping Mr A’s LTOT was reasonable, appropriate and in accordance with accepted clinical guidance. Accordingly, this aspect of Mr B’s complaint was not upheld. Mr A’s records showed that his NEWS was fairly stable throughout 11 February, and that there were no delays in escalating Mr A’s care as his condition was relatively stable. Whilst not part of the investigation remit, the investigation did identify a delay in reviewing Mr A on 10 February; based on his recorded NEWS this should have prompted an urgent medical review. However, as Mr A responded to the increased supplemental oxygen and his NEWS improved promptly, the fact that a medical review did not take place was, on balance, not unreasonable and therefore did not cause him an injustice. This part of Mr B’s complaint was also not upheld.

Mr B complained about whether hip replacement surgery arranged and funded by Swansea Bay University Health Board (“the Health Board”) and performed at Nuffield Health – The Vale Hospital (“the Private Hospital”) was carried out to an appropriate standard and the subsequent aftercare. The Ombudsman found that the prosthesis used in the hip replacement surgery was under-sized, which carried a known risk of early loosening. Whilst this risk could not be completely eliminated, measures that could have reduced the risk were not taken. This part of Mr B’s complaint was upheld. When Mr B reported concerns following surgery the action taken was appropriate and timely. This part of Mr B’s complaint was not upheld. When Mr B complained to the Health Board he was not told that he should complain directly to the Private Hospital, and whilst a complaint response was issued it did not fully address all of Mr B’s concerns. The Health Board and the Private Hospital both accepted the Ombudsman’s recommendations. The Health Board agreed to apologise to Mr B for the failures in handling his complaint and to ensure that its staff who may deal with complaints about commissioned care, are aware of the correct procedure for doing so. The Private Hospital agreed to apologise to Mr B for its failure to mitigate the risk of the prosthesis failing, and offer him a redress payment of £750 and to share the report with the Surgeon who undertook Mr B’s surgery so the findings can be considered and discussed.

Ms A complained that the Welsh Ambulance Services University NHS Trust failed to respond to the complaint she submitted in May 2025. The Ombudsman found that the Trust failed to formally respond to the complaint and said this caused uncertainty and frustration for Ms A. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Trust’s agreement to, within 3 weeks, provide the complaint response, apologise for the delay and explain why this happened, and offer a £100 financial redress payment in recognition of the time and trouble.

Mr B complained about whether hip replacement surgery arranged and funded by Swansea Bay University Health Board (“the Health Board”) and performed at Nuffield Health – The Vale Hospital (“the Private Hospital”) was carried out to an appropriate standard and the subsequent aftercare. The Ombudsman found that the prosthesis used in the hip replacement surgery was under-sized, which carried a known risk of early loosening. Whilst this risk could not be completely eliminated, measures that could have reduced the risk were not taken. This part of Mr B’s complaint was upheld. When Mr B reported concerns following surgery the action taken was appropriate and timely. This part of Mr B’s complaint was not upheld. When Mr B complained to the Health Board he was not told that he should complain directly to the Private Hospital, and whilst a complaint response was issued it did not fully address all of Mr B’s concerns. The Health Board and the Private Hospital both accepted the Ombudsman’s recommendations. The Health Board agreed to apologise to Mr B for the failures in handling his complaint and to ensure that its staff who may deal with complaints about commissioned care, are aware of the correct procedure for doing so. The Private Hospital agreed to apologise to Mr B for its failure to mitigate the risk of the prosthesis failing, and offer him a redress payment of £750 and to share the report with the Surgeon who undertook Mr B’s surgery so the findings can be considered and discussed.

Mr A complained that he had not received a Stage 2 complaint response from Powys County Council, within the defined timescales. The Ombudsman found that a Stage 2 response had not been issued to Mr A within the timescales. The Ombudsman said this left Mr A with unanswered questions regarding his complaint to the Council. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Council’s agreement to within 4 weeks, issue the Stage 2 complaint response, including an explanation of and apology for the delay.

Mrs A complained that Powys Teaching Health Board had refused to investigate her complaint without her son’s consent. Mrs A also said that the Health Board failed to respond to the concerns relating to her own experience, which did not require her sons consent. The Ombudsman found that the Health Board had overlooked providing a response to the concerns which did not require Mrs A’s sons consent. The Ombudsman said this caused uncertainty and frustration for Mrs A. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to, within 4 weeks, offer an apology for the oversight and provide a complaint response to the concerns which do not require Mrs A’s sons consent.

Mrs B complained that Cardiff Council had failed to adequately address her concerns and refused to formally respond to her complaint. The Ombudsman found that whilst the Council had correctly refused to respond to her complaint under the Social Services Complaints Process, the Council could have responded under its Corporate Complaints Process. She said that this caused frustration and uncertainty to Mrs B. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Council’s agreement to write to Mrs B to provide an apology for the failure to consider her complaint under the Corporate Complaints Process and to issue a Stage 1 complaint response within 3 weeks.

Ms B complained that Cwm Taf Morgannwg University Health Board had failed to provide a formal response to her formal complaint, which she made to it in April 2025. The Ombudsman found that whilst the Health Board had provided an informal response to Ms B, despite Ms B making it clear she had made a formal complaint, it had failed to provide a response in accordance with the ‘Putting Things Right’ procedure. She said that this caused uncertainty and frustration to Ms B. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to write to Ms B with an apology for the delay in issuing a formal complaint response, provide a further apology for the lack of regular and meaningful updates, offer to pay £75 in redress and issue a formal complaint response within 6 weeks.

Mr A complained that Swansea Bay Health Board had failed to respond to his complaint about the treatment and care his father received. The Ombudsman found that Mr A complained to the Health Board 9 months ago and had still not received a formal complaint response. The Ombudsman considered this caused Mr A and his family unanswered questions and decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to issue a full complaint response to Mr A which includes explaining the reasons and apologising for the delay within 4 weeks.

Mrs B complained that Aneurin Bevan University Health Board failed to provide a response to her complaint about her late mother, which she made to it, in June 2025. The Ombudsman found that the Health Board had failed to provide regular and meaningful updates and had not issued a complaint response. She said that this caused frustration and uncertainty to Mrs B. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to write to Mrs B with an apology and explanation for the delay, provide a further apology for the lack of updates, offer Mrs B £75 redress and issue a complaint response within 4 weeks.

Mrs A complained about the dental treatment provided to her son by Cardiff and Vale University Health Board. The Ombudsman found that the Health Board had advised Mrs A to complain to her office before issuing a complaint response in accordance with the ‘Putting Things Right’ procedure. The Ombudsman said this caused uncertainty to Mrs A about the complaints process and decided to settle the complaint without a formal investigation. The Ombudsman sought and gained the Health Board’s agreement to apologise to Mrs A for failing to provide a complaint response before signposting her to the Ombudsman’s office and to issue a full and final complaint response within 6 weeks.

Miss A complained that Ceredigion County Council had failed to respond to her request for her concerns to be considered as a formal complaint. The Ombudsman found that the Council had overlooked Miss A’s request for the matter to be considered as a formal complaint. The Ombudsman said this caused uncertainty for Miss A and decided to settle the complaint without an investigation. The Ombudsman sought and gained the Council’s agreement to, within 3 weeks, offer an apology and explanation for the oversight and issue its complaint response

Mrs A complained that she has been waiting for surgery since 2023 and the Health Board is not helping her and delaying her surgery. The Ombudsman found that the Health Board’s complaint response lacked detail and explanation as it was not compliant with the NHS “Putting Things Right” procedure. The Ombudsman said this left Mrs A with unanswered questions about her surgery and decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to within 6 weeks issue a formal complaint response, addressing the issues Mrs A raised.

Ms A complained about Swansea Council’s Social Services department and its interactions with her about her children. Ms A was dissatisfied with the Council’s response to her Stage 2 complaint. She raised concerns about the Independent Investigation report, which the Council had declined to consider. The Ombudsman found that there had been a thorough and comprehensive independent Stage 2 investigation of Ms A’s complaint, which broadly addressed her concerns. However there were some aspects of the Independent Investigation report which were not sufficiently evidenced, and requested documents had not been provided to Ms A. The Council had not considered or responded to Ms A’s concerns about the report. Ms A was inconvenienced by the Council’s actions and this had caused frustration and uncertainty for her. The Ombudsman agreed to settle the complaint without an investigation. The Council agreed to consider Ms A’s correspondence and the matters which she said are factually incorrect in the Stage 2 Investigation Report within 4 weeks. It further agreed to provide her with a written response, addressing the matters contained in her correspondence to the Council and complaint to the Ombudsman, within 8 weeks.

Mrs C complained about the care and treatment she received from a Dental Practice in the area of Betsi Cadwaladr University Health Board. Mrs C complained that the Practice did not perform dental work to an appropriate standard when it carried out 2 fillings on 27 February and 2 extractions on 20 March 2025. She also complained that the Practice did not provide appropriate aftercare following the extractions of 20 March. The investigation found that the dental work carried out by the Practice on 27 February and 20 March reached an appropriate standard, so this point of Mrs C’s complaint was not upheld. However, it found that, although the Dentist’s own aftercare was appropriate following the extractions of 20 March, there was a lapse in the Practice’s internal communication. The second point of Mrs C’s complaint was therefore upheld. The Ombudsman recommended that the Practice apologise to Mrs C for this lapse, and remind reception staff of its process regarding notifying dentists of contact from patients. The Practice agreed to implement the Ombudsman’s recommendations.

Mr B complained about whether Neath Port Talbot Council responded appropriately to reports of noise he made regarding a development near his home. The Ombudsman found that, whilst the Council’s investigation into the reports of noise made by Mr B was appropriate, the way the Council communicated with him was not. Mr B’s concerns were not fully addressed, and he was not kept informed of the progress of the investigation into his complaint. These failures amount to maladministration and are an injustice to Mr B, who was frustrated at the perceived lack of action regarding his complaint. This element of Mr B’s complaint was upheld. The Council accepted the Ombudsman’s recommendations. It agreed to apologise to Mr B for the failures of communication identified during the investigation, to remind officers of the necessity to inform complainants of the outcome of investigations and to ensure that the officers that investigated Mr B’s complaint are familiar with the Council’s Complaints Policy.

Mrs D complained about the care and treatment provided to her by Swansea Bay University Health Board. The Ombudsman considered whether the investigations conducted by the Health Board into a suspected neuroendocrine tumour (“NET” – a rare form of cancer that affects the cells that release hormones into the bloodstream) were appropriate and timely. The investigation found that the investigations conducted by the Health Board into a suspected NET were appropriate and timely. Although there had been some contradictory findings from tests and procedures that had prolonged the treatment pathway, follow up investigations were clinically appropriate. The investigation found no evidence of unnecessary delays and that Mrs D had been informed of the findings and the plans. The Ombudsman did not uphold the complaint.

Mr B complained about the treatment he received from Betsi Cadwaladr University Health Board (“the Health Board”), specifically whether a prescription of methadone (used in the treatment of opioid addiction) was managed appropriately and in keeping with relevant guidance and whether a decision not to prescribe anti depressant medication was appropriate and in keeping with relevant guidance. The Ombudsman found that the prescription of methadone was managed appropriately and consistent with relevant prescribing guidance and clinical standards. This part of Mr B’s complaint was not upheld. The decision not to prescribe Mr B anti depressant medication was also appropriate, in keeping with relevant guidance and took in to account the situation in the prison at the time. This part of Mr B’s complaint was not upheld.

Miss A complained that the Practice ignored her complaints and reasonable adjustments and did not provide her with a long covid diagnosis, despite assurances. At assessment, it was found that the Practice did not adhere to Miss A’s reasonable adjustments, that Miss A had not received a copy of the Practice’s complaint response and that the Practice had not had a chance to respond to the complaint regarding a long covid diagnosis. The Ombudsman decided to settle the complaint without investigation. The Practice agreed, within 1 week, to resend its complaint response to Miss A, and, within 4 weeks, to provide a complaint response in respect of the long covid diagnosis, apologise for not adhering to Miss A’s reasonable adjustments, and to place a note on Miss A’s medical record detailing her reasonable adjustments.

Mr C complained about the care and treatment he received between September 2023 and July 2024 following his prostate cancer diagnosis. In particular, we considered the significance of the delays in Mr C receiving a prostate-specific membrane antigen positron emission tomography scan (“PSMA PET scan” – an advanced imaging test that uses a radioactive tracer to identify and visualise prostate cancer cells). We also considered the delay in Mr C receiving hormonal therapy, and the impact this had on the spread of the cancer. The investigation found that whilst the care and treatment Mr C received, overall, followed the NHS Wales National Optimal Pathway (“NOP”) for Prostate Cancer, there were significant delays in Mr C’s journey on the NOP which led to him waiting more than 3 times as long as he should have done before his treatment was started. A biopsy in January 2024 indicated that a PSMA PET scan was appropriate for Mr C, but it did not happen for almost 4 months. This delay was unacceptable and amounted to service failure. The delays in Mr C’s pathway more likely than not contributed to his cancer being more advanced. This uncertainty will sadly be an enduring injustice for Mr C and his family, so this part of his complaint was upheld. In relation to Mr C receiving hormonal therapy sooner, the investigation found that it was appropriate for Mr C not to have started this therapy before the outcome of the PSMA PET scan was known as this would have had a potentially significant impact on the interpretation of the PSMA PET scan itself. However, as there had been a significant and unnecessary delay in Mr C undergoing the PSMA PET scan, it followed that there was also a subsequent delay in his hormonal therapy commencing. This was also an injustice to Mr C and this part of his complaint was also upheld. Of further concern was the Health Board’s failure to recognise the delays highlighted when it responded to Mr C’s complaint. In the thematic report “Groundhog Day 2”, thi

Ms T complained about how the Council responded to her regarding issues with noise transference and repairs required in her flat, as well as her requests for reasonable adjustments in communication. Overall, the Council responded sensitively and proportionately to Ms T’s complaints about noise transference within the limitations of what it was able to do. This element of Ms T’s complaint was not upheld. Whilst there were a number of factors impacting on the repairs processes but an absence of proactive follow-up and poor communication on the part of the Council contributed to long delays in getting repairs inspected and addressed. We upheld Ms T’s complaints that her repairs were not addressed within a reasonable timeframe. The Council agreed to communicate with Ms T by email “in the main” and, largely, it adhered to this agreement. However, it failed to consider Ms T’s communication needs in the context of its operational capabilities and although an informal agreement was made for Ms T’s allocated housing officer to act as a communication link, this practice was not always successful and there was no contingency in place for times when the housing officer was unavailable. It also did not help to manage Ms T’s expectations about what was possible, in terms of arranging convenient appointments, or to establish a consistent level of service. Therefore, this element of the complaint was also upheld. The Council was already in the process of reviewing and developing its Repairs Policy, exploring options for a new IT system that could meet all the requirements for the system. The Council also agreed to apologise to Ms T and offer her £500 in recognition of the failings identified. It agreed to contact Ms T to discuss her communication needs, to confirm any adjustments to support her, and to ensure that any agreed adjustments are clearly recorded and shared with Ms T and relevant staff. It also agreed to remind relevant staff of the importance of keeping tenants informed

Ms T complained about how the Council responded to her regarding issues with noise transference and repairs required in her flat, as well as her requests for reasonable adjustments in communication. Overall, the Council responded sensitively and proportionately to Ms T’s complaints about noise transference within the limitations of what it was able to do. This element of Ms T’s complaint was not upheld. Whilst there were a number of factors impacting on the repairs processes but an absence of proactive follow-up and poor communication on the part of the Council contributed to long delays in getting repairs inspected and addressed. We upheld Ms T’s complaints that her repairs were not addressed within a reasonable timeframe. The Council agreed to communicate with Ms T by email “in the main” and, largely, it adhered to this agreement. However, it failed to consider Ms T’s communication needs in the context of its operational capabilities and although an informal agreement was made for Ms T’s allocated housing officer to act as a communication link, this practice was not always successful and there was no contingency in place for times when the housing officer was unavailable. It also did not help to manage Ms T’s expectations about what was possible, in terms of arranging convenient appointments, or to establish a consistent level of service. Therefore, this element of the complaint was also upheld. The Council was already in the process of reviewing and developing its Repairs Policy, exploring options for a new IT system that could meet all the requirements for the system. The Council also agreed to apologise to Ms T and offer her £500 in recognition of the failings identified. It agreed to contact Ms T to discuss her communication needs, to confirm any adjustments to support her, and to ensure that any agreed adjustments are clearly recorded and shared with Ms T and relevant staff. It also agreed to remind relevant staff of the importance of keeping tenants informed