PSOW Individual Decisions

Mr A complained that Hywel Dda University Health Board had failed to respond to the further complaint he submitted in April 2024. The Ombudsman decided that there had been a delay by the Health Board to provide Mr A with a further response to his complaint. She said this had caused frustration and uncertainty for Mr A. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to apologise to Mr A, offer him redress of £100 in recognition of the delays and issue a complaint response within 30 working days.

Mr W complained that Hywel Dda University Health Board had failed to respond to the complaint he submitted in March 2024. The Ombudsman decided that there had been a delay by the Health Board to provide Mr W with a response tohis complaint. She said this had caused frustration and uncertainty for Mr W. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to apologise to Mr W and issue a complaint response within 30 working days.

Ms A complained about the care and treatment that her late mother received from Hywel Dda University Health Board, when she was an inpatient between January 2023 and June 2023. The Ombudsman decided that there were shortcomings in the way that the Health Board had communicated with the family following a scan, which identified suspected mestastases and how this was referred to in its complaints response. The Ombudsman said that this information could have been clear. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement that within 4 weeks it would apologise to Ms A that the family were not made aware of their mother’s suspected metastases following a scan, and apologise that the complaints response could have been clearer.

Mr D complained that Hywel Dda University Health Board had failed to issue a response to his complaint which he made to it in March2024. The Ombudsman found that the Health Board had failed to issue a complaint response. The Ombudsman said that this caused frustration and uncertainty to Mr D and decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to write to Mr D with an apology and explanation for the delay, offer£50 redress to Mr D for his time and trouble in making his complaint and to issue a complaint response within 30 days.

Ms X complained that Hywel Dda University Health Board failed to respond to her complaint submitted to it in February 2024 in respect of her aunt’s care. The Ombudsman concluded that the Health Board had failed to respond to Ms X’s complaint in line with its internal complaint process. The Ombudsman said this caused uncertainty, frustration, and inconvenience to Ms X. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to apologise for the delay, explain the reasons for the delay, and issue its complaint response, all within 6 weeks of the Ombudsman’s decision.

Miss X complained that Hywel Dda University Health Board misdiagnosed endometriosis, and failed to provide a response to the complaint she submitted to it in October 2023. The Ombudsman concluded that the Health Board had failed to respond to Miss X’s complaint in a reasonable timeframe. The Ombudsman said this caused uncertainty, frustration, and inconvenience to Miss X. 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, provide and explanation and apology for the delay, and issue a redress payment of £100 in recognition of the delay and need to approach the Ombudsman, within 4 weeks.

Mrs B complained that the treatment and care provided by the Health Board to her mother, Mrs C, fell below a reasonable standard. Specifically, Mrs B complained that Mrs C had not received appropriate orthopaedic care or treatment since her pre-assessment for left foot surgery on 4 September 2019. She further complained that Mrs C’s urinary issues were not adequately investigated from December 2020 – 3 February 2021 and that her foot infection did not receive appropriate care or treatment during this period. She raised concerns that Mrs C’s dignity was compromised when she was placed in an incontinence pad on admission to another hospital on 3 February 2021 and said the Health Board’s complaint handling was significantly delayed, and a promised meeting was not arranged. The investigation found that Mrs C received an appropriate level of orthopaedic care and treatment since September 2019 to the date of her complaint. It also found that Mrs C’s foot infection received appropriate care and treatment and that the Health Board’s management of Mrs C’s dignity was appropriate. However, the investigation found that Mrs C’s urinary issues were not adequately investigated from December 2020 – 3 February 2021 and the Health Board’s complaint handling did not reach a reasonable level. The Ombudsman recommended that the Health Board should provide Mrs B and Mrs C with an apology for the failings identified in this report. She also recommended that the Health Board should conduct an audit in the Second Hospital of 10% of patients with incontinence issues to assess whether they have been treated in line with the most recent version of the Welsh Continence Guidance and act accordingly to remedy any deficiencies found. The Health Board has agreed to implement these recommendations.

Mr and Mrs A complained that the Health Board’s treatment and care of their daughter, Ms B, who had a learning disability (“LD”), fell below a reasonable standard. Specifically, Mr and Mrs A complained that Ms B’s diagnosis and treatment were delayed, that the nursing care she received was not adequate, that her disabilities were not managed appropriately by staff, including an allegation of inappropriate restraint, and that the Health Board’s complaint handling was inadequate. The investigation found that Ms B’s diagnosis and treatment were delayed, but that this was unlikely to have made any difference to the sad outcome of her death. It partly upheld Mr and Mrs A’s concerns about the nursing care Ms B received and found that Ms B’s disabilities were not managed appropriately by staff, including the handling of Mr and Mrs A’s allegation of inappropriate restraint. Finally, it found that the Health Board’s complaint handling did not reach a reasonable standard, but that it was reasonable for it to ask Mr and Mrs A to confirm their complaint after it was paused for a number of months. The Ombudsman recommended that the Health Board apologise to Mr and Mrs A for the failings identified by the investigation and repeat its offer to pay Mr and Mrs A £250 to recognise the emotional impact of its delay in handling their complaint. She also recommended that the Health Board introduce a requirement that if any patient is awaiting tests from a specific discipline of medicine, explicit agreement must be obtained before the patient is discharged. The Ombudsman further recommended that the Health Board Develop a consistent method for logging the admission of all patients with LD to hospital, create a new audit tool, produce and disseminate a discharge toolkit to staff and assign LD Champions to all clinical areas. Additionally, she recommended additional elements to staff training on caring for people who have LD and/or autism and an audit of the LD Health Profile (Passport) an

Miss W complained that Hywel Dda University Health Board had failed to respond to her complaint regarding her aftercare treatment following surgery. The Ombudsman found that Miss W 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 W, offer her a redress payment of £50 in recognition of the delays and issue its complaint response within 4 weeks.

Ms A complained about care and treatment provided by Hywel Dda University Health Board (“the Health Board”) in relation to Rheumatology. The Ombudsman decided that it was unclear why the decision had been made not to prescribe the next biologic as per NICE guidelines, and was concerned that there clear instances of factual errors in the final response. The Ombudsman sought and gained the Health Board’s agreement to. within 6 weeks, arrange for another clinician to review the complaint to give their view on the care and treatment and answer the outstanding query on whether the consultant should have tried another biologic, consider the complainant’s request to see another consultant, and apologise for any errors in the final response, and correct these. The Health Board advised that the complainant’s request to see another consultant had already been actioned.

Mrs X complained that Hywel Dda University Health Board’s complaint response did not address her concerns. The Ombudsman found that Health Board had agreed to reinvestigate Mrs X’s complaint, however it had failed to provide her with a complaint response. She said this caused frustration to Mrs X. She decided to settle the complaint without an investigation The Ombudsman sought and gained the Health Board’s agreement to write to Mrs X with an apology and explanation for the delay and issue its complaint response within 4 weeks.

Mrs A complained that from October 2022 to March 2023 a GP Practice in the Hywel Dda University Health Board area (“the Practice”) failed to provide appropriate care and treatment for her late mother in respect of her presenting symptoms, condition and past medical history (aortic heart valve replacement in 2007). Mrs A was particularly concerned that there were inappropriate delays and missed opportunities in treating her mother and referring her urgently to the heart failure clinic. Her mother sadly died in May 2023. The investigation found that while there were learning opportunities for the Practice, mainly regarding expediting investigations in deteriorating patients, the care provided had been of an appropriate standard. Importantly, the Practice had sought, in November 2022, to expedite an echocardiogram for Mrs A’s mother and this was the key investigation for her (in accordance with NICE (2021) National Guideline 208: “Heart valve disease presenting in adults: investigation and management”, which placed echocardiographic monitoring at the centre of management). The complaint was therefore not upheld.

Mr A complained because he was unhappy with Hywel Dda University Health Board’s response to his complaint. He was also unhappy that the Health Board had not responded to further correspondence. The Ombudsman found that the Health Board’s complaint response was reasonable. However, the Ombudsman was concerned that the Health Board had failed to reply to Mr A’s correspondence of 17, 26 and 27 June 2024. The Ombudsman sought and gained the Health Board’s agreement, that within 20 working days, it would apologise to Mr A and provide him with responses to his correspondence.

Mr D complained that Hywel Dda University Health Board failed to respond to further questions following its complaint response, on18 November 2023. The Ombudsman found that there had been a significant delay answering Mr D’s additional questions. This caused frustration and uncertainty for Mr D. She decided to settle the complaint without an investigation. The Ombudsman gained the Health Board’s agreement to write to Mr D, within 6 weeks, answering his questions and apologising for the delay.

Ms B complained that she submitted a complaint to the Health Board in September 2023, regarding the care and treatment her late daughter received at Glangwili Hospital.  Ms B complained again in April 2024, about the lack of complaint response from the Health Board and ignoring requests for answers.  Ms B had still not received a response to her complaint when she brought the matter to the Ombudsman’s attention in July 2024. The Health Board agreed to issue the complaint response within 6 weeks and, as part of that response, to apologise and provide an explanation for the delay.  The Ombudsman considered this to represent an appropriate outcome and closed the case on this basis.

Mrs A’s complaint about whether the standard of care provided by Hywel Dda University Health Board’s Glangwili Hospital (“the Hospital”) to her late father (“Mr B”) during his inpatient admission between 21 November to 6 December 2021 was appropriate. Mrs A queried the correct dose of antibiotics being prescribed to her father for the correct period. She questioned whether a chest X-ray on 6 December was suggestive of an unresolved infection which would not have developed if antibiotics had been continued throughout her father’s admission, rather than being started, stopped and re-started and if a further X-ray was needed. Mrs A questioned if oxygen therapy provided to Mr B was appropriate and whether the fact that he needed a maximum amount of oxygen should have prompted further review and/or suspicion that he was in terminal decline. She also questioned the timeliness and frequency of the referral to the Haematology and the Intensive Care Unit. The Ombudsman found that Mr B was receiving daily antibiotics, and these continued until 3 December and that he received the full doses of antibiotics for the optimum period. Mr B’s underlying cancer meant that his immunity was severely compromised, and he was therefore not responding to his antibiotic treatment. Given that the chest X-ray taken on 6 December showed Mr B had developed pneumonia the Ombudsman did not consider that clinically, further chest X-rays would have added anything more and would not have been warranted. The Ombudsman found that Mr B was receiving maximum oxygen therapy. Unfortunately, his pneumonia (an opportunistic infection (these are infections which occur more often and/or are more severe in those with weakened immune systems) resulting from his severely immunocompromised state) hampered the benefit he received from the oxygen. The Ombudsman concluded that a further review by the Haematology Team and ITU would not have altered Mr B’s management or his eventual outcome. In June 2020, the Haematolo

Ms P complained that despite making a complaint to Hywel Dda University Health Board about the care and treatment provided to her late father on 21 November 2023, it had not provided a complaint response. The Ombudsman found that the Health Board had failed to issue a complaint response to Ms P and delayed seeking the necessary consent when her father was alive. She said that this caused frustration and uncertainty to Ms P and decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to write to Ms P with an apology for the identified failures and to issue a complaint response within 6 weeks.

Mrs A complained about a delay in the provision of pain relief for her mother, Mrs C, during her wait in an ambulance outside Glangwili General Hospital on 13 March 2022. She also complained about a delay in carrying out her mother’s surgery to her right hip following her admission on 14 March 2022. Finaly she complained about the delays in reviewing her mother’s moisture sores. The Health Board, as part of its investigation, had identified that on occasions there was shortcomings in measuring Mrs C’s pain levels. That said, the Ombudsman found the Health Board’s explanation for the delay in administering a nerve block (a medical procedure to help manage pain) procedure was reasonable. However, given the injustice caused to Mrs C regarding her pain management this part of her complaint was upheld. The Health Board was also asked to consider any learning from Mrs C’s case, given the national problem of patients having prolonged waits in ambulances outside of Emergency Departments before being transferred. We did not uphold Mrs A’s complaint about the delays in carrying out hip surgery as it did not have a longer-term impact on Mrs C’s care or her clinical outcome. We found that Mrs C’s care needs when it came to her personal hygiene skin management were broadly satisfactory. Although the Health Board had identified occasional episodes where Mrs C’s care was not carried out within set timescales, we were satisfied that this did not have an adverse impact on Mrs C. This aspect of Mrs A’s complaint was also not upheld. We invited the Health Board to remind all nursing staff of the need to ensure that skin integrity checks are consistently carried out in a timely manner. As part of our recommendations the Health Board was asked to apologise to Mrs A for the failing identified in the report and to share this report with its Quality and Patient Safety Committee as part of its quality assurance.

Ms A complained that Hywel Dda University Health Board (“the Health Board”) took too long to respond to her complaint. She also complained about the response to an issue referred to the Health Board by the Medical Examiner. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement that, within 30 working days, it would write to Ms A to apologise for the delayed complaint response. It would also provide further explanation for the issue referred by the Medical Examiner.

Mrs A complained that the Health Board failed to arrange regular neuropathy tests, that she had not been monitored over the last 6 years and that it failed to arrange regular diabetic eye screening tests. Mrs A complained to the Health Board on 29 April 2024 and was only provided with a 2 sentence response. She felt that her concerns were not adequately addressed. The Ombudsman agreed a settlement/early resolution with the Health Board. The Health Board agreed to carry out an investigation into Mrs A’s concerns and provide her with a complaint response under the Putting Things Right guidance. It agreed to provide this within 1 month of receiving the complaint documentation and any clarification needed from Mrs A and her advocate in order to investigate the complaint.

Mr X complained that Hywel Dda University Health Board had failed to respond to his complaint about his current care and treatment. The Ombudsman concluded that Health Board had failed to log and respond to Mr X’s complaint in line with its complaint process. She said this had caused uncertainty, frustration and inconvenience to Mr X. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to apologise to Mr X for the delay and inconvenience caused and to issue its complaint response within 3 weeks.

Mr B was unhappy that Hywel Dda University Health Board did not respond fully to the concerns that he had raised. The Ombudsman found that the Health Board’s complaint response had not provided full explanations for actions it had taken and did not respond to Mr B’s concern that he was made to feel like his hip surgery was imminent. The Ombudsman sought and gained the Health Board’s agreement to provide Mr B with an apology for not fully addressing his concerns, to provide an updated response to his complaint, and to provide an update in respect of his treatment plan, within 20 working days.

Mrs B complained to her GP Practice about care and treatment she had received. This included concerns about a letter she had received from a GP, concerns about her pain management, incorrect information in hospital referrals and access to her medical records. Mrs B complained to the Ombudsman that the response she had received from the GP Practice was brief and did not fully address the concerns she had raised. The assessment of Mrs B’s complaint identified that some aspects of her complaint had not been sufficiently addressed by the GP Practice. The GP Practice agreed to issue a further response to Mrs B. This will include a response to her concerns about pain management and confirmation that her records have been updated to reflect her allergies and current height measurement. The Ombudsman considered the actions taken by the GP Practice were reasonable to settle this complaint and it was closed on that basis.

Mrs H complaint that the Surgery failed to provide a response to her complaint, which she made to it in January 2024. The Ombudsman found that whilst the Surgery had acknowledged the complaint, it had failed to provide a complaint response. The Ombudsman said that this caused frustration and uncertainty to Mrs H and decided to settle the complaint without an investigation. The Ombudsman sought and gained the Surgery’s agreement to write to Mrs H with an apology and explanation for the delay in responding to her complaint and to issue a complaint response within 10 working days.

Mrs A complained that Hywel Dda University Health Board failed to properly apologise or explain the reasons for the delay in responding to her complaint about her husband’s care. The Ombudsman found that the Health Board had offered an apology in its response but had failed to explain the reasons for the delay in responding, which the Ombudsman said had caused Mrs A and her husband additional stress. The Ombudsman sought and gained the Health Board’s agreement to apolgise for the additional stress caused to Mrs A and her husband by the delay and to explain the reasons for the delay within 4 weeks.