PSOW Individual Decisions

Miss A complained that there was a 7-week delay between her diagnosis with acute cholecystitis (inflammation of the gallbladder) on 16 November 2021 and surgery to remove her gallbladder on 5 January 2022. Miss A queried whether having her gallbladder removed sooner might have prevented the need for her to undergo open surgery. The investigation found that the management of Miss A’s acute cholecystitis by the Health Board was consistent with accepted good practice and the relevant guidelines at all times. The decision to undertake open surgery did not indicate that there was a fault with the care Miss A received. Also, there was no inappropriate delay between Miss A’s diagnosis of acute cholecystitis and surgery to remove her gallbladder. Accordingly, the complaint against the Health Board was not upheld.

Mrs A complained about the care provided to her late sister by Cardiff and Vale University Health Board and a GP Practice. The Ombudsman found that Mrs A complained to the Health Board in 2022, but she had not received a formal response to her complaints under the Putting Things Right NHS complaints process. She said that this caused uncertainty for Mrs A. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Heath Board’s agreement to, within 30 working days: • provide a formal complaint response to Mrs A, to include a response from the GP Practice. • apologise to Mrs A and offer her a payment of £250 to reflect the uncertainty caused.

Mrs A complained about the care provided to her late sister by Cardiff and Vale University Health Board and a GP Practice. The Ombudsman found that Mrs A complained to the Health Board in 2022, but she had not received a formal response to her complaints under the Putting Things Right NHS complaints process. She said that this caused uncertainty for Mrs A. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Heath Board’s agreement to, within 30 working days: • provide a formal complaint response to Mrs A, to include a response from the GP Practice. • apologise to Mrs A and offer her a payment of £250 to reflect the uncertainty caused.

Mr C complained about the care and treatment his late wife, Mrs C, received from Cardiff and Vale University Health Board (“the Health Board”) between November 2021 and March 2022. He said the Health Board missed opportunities to diagnose her brain tumour earlier. In particular, we investigated whether Mrs C’s computerised tomography scan (“CT scan” – the use of X-rays and a computer to create an image of the inside of the body) on 15 November 2021 was correctly interpreted, whether Mrs C underwent appropriate tests on 5 January 2022 and if she was discharged appropriately and whether, during Mrs C’s last admission, she was assisted appropriately with eating food, and whether Mr C was informed that extra visitations were possible as she was at end-of-life. The investigation found that the CT scan taken on 15 November 2021 was interpreted correctly and this part of the complaint was not upheld. The Ombudsman found that although Mrs C was well enough to be discharged, her facial swelling was not investigated further. Had it been, an earlier diagnosis of cardiac angiosarcoma would have been made and Mrs C would have remained under the care of the Health Board. This part of the complaint was upheld. During Mrs C’s last admission, there were missed opportunities to complete numerous templates to evidence her nursing care in relation to nutritional assessment, provision of nutrition and assistance with eating and drinking. There were also missed opportunities to robustly complete strict fluid intake and output monitoring. Finally, in relation to extra visitations, whilst there was evidence of a discussion taking place with Mr C regarding extended visiting arrangements, Mrs C would have benefitted from this if this had been initiated sooner. This part of the complaint was also upheld. The Ombudsman recommended that the Health Board apologise to Mr C, reimburse him the sum of £2,022 to cover the private consultations and scans and share the report at the Hospital’s Medicine

Ms M complained that Cardiff and Vale University Health Board failed to issue a response to her complaint, which she made to it in July 2023. The Ombudsman found that the Health Board had delayed requesting additional information from Ms M to enable it to undertake its investigation and had failed to issue a complaint response. She said that this caused frustration and uncertainty to Ms M. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to write to Ms M with an explanation for the delay in responding to her complaint and provide apologies for the identified failures within 2 weeks. Furthermore, it was agree that the Health Board would offer £75 redress to Ms M in recognition of her time and trouble in making her complaint to the Ombudsman and issue a complaint response within 6 weeks.

We investigated a complaint made by Mrs B about the treatment she received from Cardiff and Vale University Health Board (“the Health Board”). In particular: a)The reasonableness of the decision not to re-surface her kneecap during the total knee replacement operation on 1 September 2021. b)Whether, after her operation, the appropriate clinical investigation and assessments into her ongoing knee pain symptoms were carried out, and whether this was done in a timely way. Specifically, to consider the period between 18 October 2021 (the first post-operative outpatient appointment with the Consultant Surgeon) and 8 June 2022 (the date of her private consultation and decision to re-surface the knee). What we found The investigation found that the decision not to re-surface Mrs B’s kneecap during the total knee replacement operation on 1 September 2021 was reasonable, as was the clinical investigation and assessments into her ongoing knee pain symptoms between 18 October 2021 and 8 June 2022. The Ombudsman did not uphold Mrs B’s complaints.

Mrs A complained about her late husband’s inpatient management and care after he fractured his left ankle, as well as communication with the family during his inpatient admission at Llandough Hospital and University Hospital of Wales between December 2022 to February 2023. Sadly, Mr A died on 16 February. Mrs A also expressed dissatisfaction with the Health Board’s handling of her complaint including its withdrawal of an offer to meet the family made in its complaint response. The Ombudsman concluded that an investigation would not achieve much more, given that the independent Medical Examiner’s Service had not identified any clinical failings. The Ombudsman noted that the Health Board had acknowledged and apologised for the considerable delay in responding to Mrs A’s complaint which it said was due to the Service experiencing unprecedented demand and which had impacted on its ability to respond in a timely manner. Given the shortcomings in the Health Board’s complaint handling, the Ombudsman was critical that the Health Board had withdrawn its offer to meet Mrs A and the family. The Ombudsman took the view that in the circumstances, this was not appropriate and was satisfied that this, along with the delay, would have further added to the family’s distress. The Health Board as part of an early resolution agreed that within 6 weeks it would write to the family and provide them with an opportunity to meet with the Health Board to discuss their concerns around communication. It would also update the family on lessons learnt from Mr A’s case and review its complaint handling process. This was to ensure that offered meetings were not rescinded when complainants took up the offer to meet.

Ms C complained about the haemophilia care and treatment she received at the University Hospital of Wales (“the Hospital”). She raised concerns about dental treatment in August 2022 and her post-operative haemophilia care. When Ms C underwent a further dental extraction in September, she again had concerns about the appropriateness of her subsequent haemophilia care. Ms C’s concerns also extended to the haemophilia treatment plan for her scheduled cholecystectomy (gall bladder removal) at the Hospital later the same year. The Ombudsman’s investigation found that the treatment plans and subsequent haemophilia care provided to Ms C were appropriate for both dental extractions in August and September 2022 and in preparation for the scheduled cholecystectomy in December 2022. Based on the Ombudsman’s findings the 3 parts of Ms C’s complaint were not upheld.

Mr B complained that the Health Board had not appropriately considered his family member’s case as part of its nosocomial review process. In particular, Mr B considered that his family member was placed on a “covid ward” and this was not addressed in the Health Board’s decision letter. The investigation found that the decision letter contained insufficiently detailed reasons for the Health Board’s conclusion that there was no qualifying liability of harm to Mr B’s family member. The decision letter also did not address whether there was an opportunity for Mr B’s family member to have been discharged sooner and whether that would have affected the outcome. This caused injustice to Mr B as the Health Board had not provided sufficient information to explain how it had reached its decision. The Ombudsman sought and gained the Health Board’s agreement to carry out a fresh, thorough, nosocomial review, to include consideration of nosocomial, duty of care and qualifying liability issues. The need to address the discharge planning issues and COVID-19 status of the ward in its response was highlighted. The Health Board agreed to write to Mr B with a fulsome explanation of the reasons for its decision and provide a copy to this office within 6 weeks.

Mr and Mrs A complained about the care their daughter, Ms B, received from the Health Board. They complained that Ms B’s treatment was delayed: specifically, she was transferred to hospital on 17 March, but her chemotherapy did not begin until 24 March. They also complained that Ms B was not monitored closely enough following the commencement of her chemotherapy, including whether Mrs A’s concerns over the level of Ms B’s blood pressure overnight from 24-25 March were addressed and whether sepsis should have been identified sooner. The investigation found that the week that passed before Ms B commenced chemotherapy was reasonable owing to the other care and treatment she needed. This complaint was not upheld. The investigation also found that Ms B had experienced several episodes of infection/sepsis and that they had been treated appropriately. However, the monitoring of Ms B following her chemotherapy was not adequate in terms of frequency and escalation, and the appropriate chart for a patient with learning difficulties was not used throughout Ms B’s care. These failures caused an injustice to Ms B and Mr and Mrs A because Ms B’s deterioration was not highlighted, so Mr A was not with Ms B and Mrs A during Ms B’s final hours. This complaint was partly upheld on this basis. The Ombudsman recommended that the Health Board should provide Mr and Mrs A with a written apology for the failings identified in this report. She also said the Health Board should remind nursing staff of the levels at which care should be escalated and the corresponding frequency of observations. Finally, she recommended nursing staff should be reminded that an appropriate chart should be used for patients with learning difficulties. The Health Board accepted the findings of the investigation and the Ombudsman’s recommendations.

Mr A complained about the way in which the Health Board communicated with the family during his late wife’s inpatient stay from 1 June 2022, given the family had a Lasting Power of Attorney (LPA). Mr A also had concerns about the X-ray changes in his wife’s shoulder region following a fracture and whether this had been caused by the mishandling of his wife by Health Board staff. From a review of Mrs A’s medical records, the Ombudsman found it disappointing that the level of engagement with the family between 3 June to 12 July did not suggest that due consideration had been given to their legal LPA status and the implications of this, particularly given Mrs A’s later poor prognosis. This would have caused the family an injustice. The first demonstrable consideration of the LPA in the records had not occurred until 13 July. The Ombudsman noted the Health Board’s comments that there was no indication that the care provided had an adverse effect on Mrs A’s shoulder fracture. The Health Board also acknowledged that a meeting with another orthopaedic consultant to consider Mrs A’s X-rays had been suggested but regrettably not progressed. It added that its Orthopaedic Team had offered their apologies for this omission and for the poor impression the family had been left with as a result. The Health Board as part of a settlement agreed that it would write to the family to arrange a meeting with them and the Clinical Director of Trauma and Orthopaedics. The meeting would discuss the X-rays and address questions that the family might have. In addition, the process and timescale for the family to receive the X-ray images would be provided to the family. The Health Board also agreed to provide details of the changes in the LPA process that it had introduced as a result of Mr A’s complaint. It would also review how it documented LPAs to improve their visibility on a patient’s medical records as well as identifying a system for ensuring LPA documentation is followed up and presen

. The complaint related to care provided to Mrs C, a tetraplegic patient, during a hospital admission in April/May 2022 at the University Hospital of Wales (“the Hospital”). The Ombudsman found no concerns in relation to the medical care provided to Mrs C and did not uphold the complaint about the decision to discharge her. However, the investigation found that clearer information about her ongoing care could have been provided, on discharge, to carers and family. The complaint about discharge arrangements was therefore upheld to that limited extent. The investigation also identified inconsistences in the manner that Mrs C’s fundamental care needs were assessed and documented in the care plans. Detailed information provided on admission about Mrs C’s needs and preferences was not always properly translated into the care plans. This meant that there were occasions when care was not tailored to Mrs C’s specific needs. This element of the complaint was upheld. The Ombudsman recommended that the Health Board should provide an apology to the family, and an opportunity for them to share their experiences with Health Board staff. The Health Board confirmed it was currently evaluating how to improve its provision of individualised care to patients with complex physical needs. It agreed to complete this within 4 months and share a copy of the evaluation, and any associated action plan, with the Ombudsman’s office. A copy of the Ombudsman’s report was also to be provided to the Health Board’s Equalities Lead.

Ms C complained about the care provided to her father, Mr A, by Cardiff and Vale University Health Board (“the Health Board”) when he suffered an unwitnessed fall in the early hours of 10 August 2023. We investigated whether there were appropriate falls risk assessments and prevention measures in place for Mr A, and whether he was being monitored appropriately. The Ombudsman found that all appropriate risk assessments were in place to consider Mr A’s personal risk of falling, including whether bedrails should be used. It was appropriate for him to have bedrails in place at the top of the bed (“half top bedrails”). The bed was at its lowest setting and a urine bottle and call bell were within Mr A’s reach. Mr A was not confused or disorientated, and he got out of bed independently. There was nothing further that should have been done to prevent Mr A’s fall. The complaint was not upheld.

The Ombudsman investigated a complaint from Miss C, on behalf of her mother-in-law Mrs B, about care and treatment that Mrs B’s late husband, Mr B, received from the Health Board during his hospital admission in May 2022. She complained that Mr B’s personal care and continence needs were not met, that his medication was not administered appropriately, and that medical staff failed to properly investigate and treat Mr B’s infection. She also complained that Mr B was discharged from hospital without a reasonable discharge assessment, resulting in his re-admission to a separate hospital within 48 hours. The investigation also considered whether the hospital failed to implement a Deprivation of Liberty Safeguard (“DOLS”) to ensure that Mr B was being lawfully detained and whether it took his diagnosis of post-traumatic stress disorder (“PTSD” – an anxiety disorder caused by very stressful, frightening or distressing events) into account. The investigation found that Mr B’s personal care and continence needs were not met and did not reach acceptable standards. This compromised Mr B’s privacy and dignity and was an injustice to him. The investigation found that Mr B’s pain relief medication was appropriately reviewed and administered. However, medication prescribed for agitation(a state of anxiety or tension) was not administered and there was no reason for this, given Mr B’s preexisting PTSD and ongoing agitated state. These complaints were therefore upheld. It was determined that the investigation and treatment Mr B received for his infection was appropriate and the standard of clinical care was acceptable. Mr B was also appropriately discharged, having received appropriate clinical review. These complaints were not upheld.

Miss C complained about the care and treatment her late mother, Mrs A, received from Cardiff and Value University Health Board. Specifically, she complained that care and management of Mrs A’s leg wound was not of an appropriate standard during November and December 2021, prior to her admission to the University Hospital of Wales (“the First Hospital”). She also complained that diagnosis, treatment and care whilst Mrs A was an inpatient at both the First Hospital and Llandough Hospital (“the Second Hospital”) was not of an appropriate standard. She said discharge planning, care and management was inadequate for the period between Mrs A’s discharge from the First Hospital and her admission to the Second Hospital, and that communication with Miss C (Mrs A’s carer) was poor at both Hospitals. The investigation found that the care and management of Mrs A’s leg wound prior to her admission was of an appropriate standard, as was communication with Miss C at both Hospitals. However, the diagnosis, treatment and care during Mrs A’s first admission fell below an appropriate standard, as did discharge planning, care and management. The Ombudsman recommended the Health Board should apologise to Miss C for the failings identified in this report. She also said the Health Board should remind nursing staff of the requirements for care of patients who have vulnerable pressure areas and remind district nursing staff and ward nursing staff regarding the care of patients at risk of wound infection. Finally, she recommended the Health Board should remind occupational therapists to review the Royal College of Occupational Therapist Falls guidelines regarding home visit good practice.

Mrs A complained that there was an unreasonable delay by the Health Board in securing appropriate clinical treatment for her daughter, B, between March 2021 – when she first attended University Hospital of Wales with a jaw dislocation – and October 2021 when she was referred to a specialist hospital for children outside the Health Board’s area for treatment. The Ombudsman was satisfied that overall, there was no unreasonable delay in securing appropriate treatment for B and that the management strategy pursued by the Health Board was clinically appropriate, except for the regularity of reviews and the detail of the records in relation to elastic bands fitted to B’s teeth to try to prevent her jaw dislocating while she was awaiting more curative treatment. The complaint was therefore upheld to this very limited extent and only in relation to the management of B’s bands. The Health Board agreed to apologise in writing to B and Mrs A for the failings identified in relation to the management of B’s bands. It also agreed to remind relevant staff of the importance of reviewing bands regularly and documenting the details of the treatment being recommended.

Miss P complained that Cardiff and Vale University Health Board failed to provide a response to her complaint which she made to it in July 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 Miss P. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to write to Miss P with an apology and explanation for the delay in responding to her complaint, offer to pay £50 redress to Miss P for her time and trouble in raising her complaint with the Ombudsman and issue a complaint response within 4 weeks.

Mrs W complained about the care and treatment provided to her son, Mr Y, by the Health Board. Mrs W queried whether opportunities were missed during September-November 2020 by the Trauma and Orthopaedic team to identify signs that Mr Y had Motor Neurone Disease (“MND” – a rare condition that progressively damages parts of the nervous system). She also asked whether an opportunity was missed on 28 February 2022 by the treating doctor to consider whether, or identify signs that, Mr Y had MND and said complaint handling was poor and information was not shared with Mr Y’s family in good time. The Ombudsman found that Mr Y had no symptoms which would have suggested he was suffering from MND in 2020, so this complaint was not upheld. The Ombudsman also found that appropriate investigations were undertaken following Mr Y’s GP’s referral in February 2022, and in any event, it was unlikely that progress of the disease or the outcome would have been any different if he had been diagnosed earlier. The Ombudsman therefore did not uphold this part of the complaint. Finally, the Ombudsman considered the Health Board’s complaint handling and response was appropriate, so did not uphold this part of the complaint. As the Ombudsman did not uphold Mrs W’s complaint, no recommendations were made to the Health Board.

Ms N complained that a GP surgery in the Cardiff and Vale University Health Board area (“the Surgery”) failed to address her concerns that it issued a letter containing medical information to her shared home address without an addressee. The Ombudsman found that the Surgery omitted to address this aspect of her complaint which caused additional frustration to Ms N. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Surgery’s agreement to write to Ms N with its apology and explanation of what went wrong.

Mrs Y complained about the care and treatment received by her daughter, Z, from Cardiff and Vale University Health Board (“the Health Board”). Specifically, Mrs Y complained that the Health Board did not assess or investigate her daughter’s symptoms appropriately when she presented to the University Hospital of Wales between 10-12 May 2022, thereby leading to a failure to diagnose her adult bowel malrotation (when the bowel twists and causes a blockage) in a timely manner and that it did not handle her complaint appropriately. The investigation found that Z’s symptoms were not assessed or investigated appropriately on the first 2occasions she attended the Hospital. Record keeping relating to Z’s care was not of an acceptable standard and a referral to a clinic for further tests was not made. These are service failures and led to an avoidable delay in Z being diagnosed with adult bowel malrotation. The investigation also found that Mrs Y’s complaint was not handled appropriately, and she was given unrealistic expectations for when she was likely to receive a response to her complaint. This is a failing and a source of great frustration to Mrs Y. Both parts of Mrs Y’s complaint were upheld. The Ombudsman recommended that the Health Board should apologise to Mrs Y and offer her financial redress in recognition of the failures identified in the investigation. The Ombudsman also recommended that the Health Board should undertake a review of the referral process for the clinic and ensure that there is a system in place to identify when comments on complaints are overdue.

Ms C complained about whether the treatment she received at the University Hospital Llandough on 6 July 2021 was appropriate. Ms C said that she had been given an incorrect diagnosis and prognosis which led her to close her business and suffer much mental anguish. The investigation found that the care provided to Ms C when she attended the Hospital on 6 July 2021 was overall, of an appropriate standard. A correct clinical diagnosis was made, and the evidence showed that this was explained to Ms C. The Ombudsman did not uphold this complaint.

Mrs A’s complaint related to the care and treatment that she received from Cardiff and Vale University Health Board (“the Health Board”). Specifically, Mrs A complained that the Health Board had failed to diagnose her with a vesico-vaginal fistula (an abnormal opening between the bladder and vagina) in a timely manner. She also complained about the length of time that the Health Board had taken to respond to her formal complaint. The Ombudsman found that there were missed opportunities in the investigation of Mrs A’s urinary symptoms and that there should have been a stronger suspicion among clinicians of a vesico-vaginal fistula being the cause of these symptoms. The Ombudsman also found that there were delays between clinic appointments and investigations throughout the period under review. As a result, the Ombudsman concluded that there was a failure to diagnose Mrs A’s vesico-vaginal fistula in a timely manner and so upheld this aspect of the complaint. The Ombudsman also upheld Mrs A’s complaint in relation to the Health Board’s handling of her complaint. The Ombudsman recommended that the Health Board apologise to Mrs A and offer her a payment of £750 in recognition of the distress and frustration caused by the failings identified in the investigation. The Ombudsman also recommended that her investigation report was shared with the relevant clinicians involved in Mrs A’s care for them to reflect on its findings for learning purposes. Finally, the Ombudsman recommended that the investigation report be discussed at the Health Board’s Quality and Safety meeting (or in an alternative appropriate forum) and to consider whether any actions or improvements could be taken forward as a result of that discussion.

Mr A complained, on behalf of his partner, that Cardiff and Vale University Health Board (“the Health Board”) had failed to undertake a thorough investigation into their complaint or respond fully to the issues raised in respect of the care and treatment that his partner received following the birth of their child. The Ombudsman found that the Health Board’s complaint responses had addressed the issues raised in relation to the midwifery and nursing issues and that the actions identified and/or taken by the Health Board appeared broadly appropriate. However, the Ombudsman found that the Health Board had failed to provide an adequate response in relation to the issues raised about the Mental Health Liaison Team and/or the Psychologists involved in providing care and treatment. The Ombudsman contacted the Health Board and in resolution of Mr A’s complaint it agreed to, within 20 working days, provide a further and more detailed complaint response addressing the concerns raised in the complaint to the Ombudsman, together with an apology for its failure to address those concerns when investigating the complaint and providing earlier responses. The Ombudsman considered this to be an appropriate resolution and did not investigate the complaint.

Mrs W complained about the care and treatment her son, Y, received from Cardiff and Vale University Health Board between his birth in August 2017, and December 2022. Specifically, she complained that the Health Board failed to carry out appropriate investigations and tests to diagnose Y with a bowel duplication and recto-urethral fistula (where a small hole forms between the urethra and rectum) and failed to refer Y to a specialist hospital at the appropriate time. The investigation found that there was a delay in Y receiving a diagnosis for his symptoms and this complaint was upheld. It was also found that while it was appropriate to refer Y to a specialist hospital in August 2022, when faeces was found in his urine, it would have been appropriate to refer him earlier due to his ongoing unexplained symptoms. This complaint was also upheld. The Health Board agreed to apologise to Mrs W for the failings identified and make a financial redress payment of £1000 in recognition of the stress and continued discomfort caused by the delay in carrying out appropriate tests and requesting a second opinion. It also agreed to share the final report with relevant clinicians, remind them of the need to have multi-disciplinary team meetings with all relevant clinicians and all images available for children with complex issues, and remind them that for complex children where there is no improvement in symptoms to seek a second opinion.

The Ombudsman investigated a complaint made by Ms B, regarding the care and treatment her late mother, Mrs C, received from Cardiff and Vale University Health Board. In particular, Ms B was concerned that Mrs C was not provided with appropriate information and medication in preparation for her capsule endoscopy procedure (where a small capsule sized camera is swallowed and captures images as it moves through the digestive tract, to enable examination of the lining of the small bowel),and that Mrs C’s history of diabetes was not appropriately assessed by clinical staff on 8 June 2021 both prior to, and following, the procedure. Ms B also complained that the laxative bowel preparation provided to Mrs C prior to the procedure ultimately caused her death. The investigation found that although the bowel preparation medication provided to Mrs C in advance for her capsule endoscopy was appropriate, the information provided to her about diabetic medication management (including the impacts and implications of that) and the need to seek advice from her diabetic specialist nurse, was not adequately documented. Neither was Mrs C’s high blood sugar level re-checked on the day of her procedure, to identify if any further assessment or intervention was required and whether Mrs C was fit to proceed. The Health Board failed to meet an appropriate standard of care in those respects and these complaints were upheld. The Ombudsman was unable to make a finding on whether the bowel preparation ultimately caused Mrs C’s death. This is not something the Ombudsman can consider and determination of the cause of death is the legal function of the Coroner. The Ombudsman recommended that the Health Board apologise for the failings identified and that it should review its clinical guidelines for endoscopy to ensure appropriate diabetic advice and medication assessment is addressed. It was recommended that the pre procedure assessment questions and the patient information leaflet be updated to e