PSOW Individual Decisions

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

Miss A complained that the Council failed to issue the Stage 2 outcome of her complaint within a reasonable time, despite being told her investigation was complete. The Ombudsman found that this leaves Miss A with unanswered questions about the outcome of her complaint and 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 response letter to Miss A.

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

The Ombudsman investigated Mr C’s complaint about whether his grandfather, Mr A, was appropriately managed and treated when he was admitted to Ysbyty Glan Clwyd between 11 and 20 December 2024. In particular, it considered whether Mr A’s nutritional needs had been met during this period. The investigation also looked at Mr C’s complaint handling concerns. The Ombudsman’s investigation found that broadly Mr A was appropriately managed and his nutritional needs were adequately met. However, the investigation identified that neurological observations that Mr A underwent following an unwitnessed fall on 13 December were inadequate. Despite this there did not appear to have been any adverse effect on Mr A, and the observations were in accordance with Betsi Cadwaladr University Health Board’s (“the Health Board’s”) policy. The investigation found that information about a further fall that Mr A sustained while in the Emergency Department was not communicated to Mr A’s family or recorded in his medical or nursing records. The Ombudsman’s investigation concluded that record keeping fell short of the professional standards expected. It was to this limited extent only that Mr C’s complaint was upheld. The Ombudsman found that the Health Board’s complaint response was not as complete as it could have been, as the communication and documentation shortcomings relating to Mr A’s second fall were not addressed. The Ombudsman’s investigation concluded that the administrative shortcomings around complaint handling meant that opportunities were missed for the Health Board to learn lessons, it also caused Mr C an injustice as he had to complain further in order to get answers. This aspect of Mr C’s complaint was upheld. The Ombudsman’s recommendations included the Health Board apologising to Mr C; and in order to facilitate learning, sharing the report with staff involved in Mr A’s care and the Health Board considering whether to update its falls policy to provide additional clarity ar

Mr A complained about the care and treatment provided to him by the Health Board for his various health conditions. Mr A also complained about the Health Board breaching the Armed Forces Covenant duty. The Ombudsman found that the Health Board had not provided a response to the complaint Mr A made in May 2025 and when he raised further concerns, they were not acknowledged or responded to as a complaint. This caused additional frustration and uncertainty for Mr A. The Ombudsman decided to settle the complaint without an investigation. The Health Board agreed the Ombudsman’s proposal to provide a formal response to the complaint Mr A made in May 2025 within 4 weeks, and to apologise for the delay. The Health Board also agreed to provide written acknowledgement of Mr A’s further concerns within 1 week and to make all reasonable attempts to agree the parameters of the further complaint with Mr A within 4 weeks and to provide written confirmation that it will respond to the agreed complaint under Putting Things Right.

The Ombudsman received a complaint that a Member (“the Member”) of Flintshire County Council (“the Council”) had breached the Code of Conduct. It was alleged that the Member’s conduct during the time leading up to the Council’s vote on its Local Development Plan (“LDP”) was disrespectful and disparaging towards Council officers; that the Member attempted to improperly influence the vote of other members of the Council and failed to disclose a personal and prejudicial interest in the LDP. It was further alleged that the Member failed to declare a personal and prejudicial interest during a Council meeting on 24 January 2023, when the Council voted to approve its LDP. Information was obtained from the Council. Witnesses, including the Complainant, were interviewed. Information was obtained from the Member, who was also interviewed. The Ombudsman found that the Member’s conduct in the time leading up to the Council’s vote on its LDP did not amount to a breach of the Code. The Ombudsman found that the Member had declared a personal interest relating to the LDP during the meeting on 24 January 2023. However, he had failed to appropriately declare a prejudicial interest. It was found that his conduct was therefore suggestive of a breach of the Code. In considering whether the Member’s failure to appropriately declare a personal and prejudicial interest in the LDP merited further action, consideration was given to advice the Member had been provided by the Monitoring Officer, as well as the Member’s refusal to accept the advice, which was an aggravating factor. It was also considered that the member was a relatively new member of the Council at the time of events and that, whilst his failure to declare a prejudicial interest was considered a serious breach of the Code, it was noted that his involvement in the meeting did not impact the Council’s ultimate decision on the LDP. It was noted that the Member subsequently applied to the Standards Committee for dispensation in rel

Ms C complained about the actions of the Health Board in determining whether her father, Mr D, was eligible for NHS Continuing Health Care (“CHC”) funding. Mr D had significant and specific care needs due to early onset dementia. The Ombudsman investigated whether: a) the process followed by the Health Board to assess Mr D’s eligibility for CHC funding was in line with the National Framework b) the Health Board appropriately addressed the issue of Mr D’s CHC funding eligibility in its response to the complaint. c) the Health Board’s response to the complaint was timely and reasonable. The Ombudsman’s investigation found that the Health Board had not followed the process to determine Mr D’s CHC eligibility in line with the National Framework. This constituted maladministration. Following complaints from Mr D’s MS and Ms C, the remedial action taken by Health Board was inadequate. Its reasoning for the current funding position was unclear, and it had not properly addressed the potential financial implications for Mr D of the maladministration going back to the point he was discharged from hospital. The Ombudsman upheld all 3 parts of the complaint. The Ombudsman made a number of recommendations, which were accepted by the Health Board. These included: • an apology to Ms C • ensuring that it had now reached a CHC eligibility decision in line with the Framework • undertaking a retrospective review of Mr D’s CHC eligibility for the whole period dating back to his discharge from hospital • reviewing its dispute resolution process (with the Council) • arranging a joint review (with the Council) to identify improvements arising from the shortcomings identified in this case.

Mr A complained about works carried out at his home by a contractor on behalf of Codi Group (“the Body”). The Ombudsman noted that despite Mr A putting his complaint to the Body, the contractor had responded. The Ombudsman was concerned that there was no formal response from the Body. The Ombudsman sought and gained the Body’s agreement to, within 2 weeks, apologise to Mr A for not responding, and set out the scope of his concerns. Then, within 6 weeks, to respond to Mr A directly under its complaints procedure.

Mrs A complained that Aneurin Bevan University Health Board failed to respond to the complaint she submitted in July 2025. The Ombudsman found that the Health Board had failed to provide Mrs A with a formal complaint 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 Health Board’s agreement to, within 4 weeks, issue the complaint response, apologise for the delay and explain why this happened.

Mrs A complained that the Health Board had failed to respond to her complaint and of its lack of communication. The Ombudsman found that the Health Board failed to investigate the complaint within the relevant timescale and it failed to keep Mrs A updated. She said this caused uncertainty and frustration for Mrs A. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to, within 3 weeks, offer an apology and explanation for the delay and lack of communication, issues its complaint response and offer a £100 redress payment.

Ms A complained that the Practice failed to respond to aspects of the complaint she submitted in June 2025. The Ombudsman found that, while the Practice had responded, it had failed to respond to all of the concerns raised. The Ombudsman said this caused uncertainty and frustration for Ms A and decided to settle the complaint without an investigation. The Ombudsman sought and gained the Practice’s agreement to, within 2 weeks, offer an apology to Ms A for not addressing all the concerns and explain why, in addition to also providing a complaint response that responds to the concerns that were not addressed originally.

Mrs C complained that Hywel Dda University Health Board (“the Health Board”) asked her and her son inappropriate questions as part of an ADHD assessment, which caused them unnecessary distress. The Ombudsman recognised the concern that the questions had caused, but decided that the use of the questionnaires was consistent with National Guidelines and had been used appropriately. However, the Ombudsman found that there were errors in the complaints response, which wrongly suggested that Mrs C had asked her son to complete the wrong form. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to write to Mrs C within 4 weeks to apologise for the incorrect information in the complaint response, and for suggesting that Mrs C had made an error, when she had not.

Mr C complained about the care that Swansea Council (“the Council”) provided to his son, Mr A, who is an adult with support needs. He raised concerns about safeguarding, communication, representation and management of finances. Mr C also complained that the Council had failed to adequately respond to his complaints about the service provided to his son. The Ombudsman found that there were errors and significant delays in handling Mr C’s complaints between 2018 and 2025. Even when complaints were upheld, the Council did not take action to put things right. This damaged the relationship between Mr C and the Council and led him to lose confidence in the Council’s commitment to supporting Mr A. The Ombudsman considered that the Council had not taken appropriate action to ensure that Mr A’s needs were met and that his rights were upheld. The Ombudsman proposed that the Council should take action to resolve the complaint. The Council agreed to write to Mr C within 1 month to apologise for the poor communication and handling of his complaints, address the unresolved issues and offer Mr C a financial remedy in recognition of the time and trouble taken to pursue his complaint. The Council also agreed to undertake a review of arrangements relating to Mr A’s finances within 3 months. The Ombudsman considered that it was appropriate to settle the complaint on the basis of this action.

Mr A complained that Betsi Cadwaladr University Health Board had not fully addressed his complaint about the care provided to his late mother. The Ombudsman found that the Health Board’s complaint response had not adequately addressed the concerns Mr A had raised in his complaint. This amounted to maladministration which caused Mr A an injustice. Instead of investigating the complaint, the Ombudsman obtained the Health Board’s agreement to apologise to Mr A for failing to adequately address his concerns and to issue a further complaint response which sought to remedy this. The Health Board agreed to undertake these steps within30 working days.

Mrs A complained that Betsi Cadwaladr University Health Board failed to provide sterile and hygienic catheter care, and support her in her catheterisation regime, whilst she was inpatient. Mrs A believes that this resulted in her contracting an infection. The Ombudsman identified that it was documented that Mrs A was to have hourly catheter flushes, however, there was a lack of documentation to support the clinical decision making. The Ombudsman sought and gained the Health Board’s agreement to within 4 weeks, provide Mrs A with a further response on the issue identified and if possible, provide an explanation on why hourly flushing was indicated. Further, to reconsider and respond to Mrs A’s concern that the care and treatment provided contributed to the infection, in light of the issue identified.

Mr B complained that Newport City Council failed to respond to his complaint about money being debited from his wife’s account. The Ombudsman found that whilst the Council had responded to Mr B, it had failed to log a formal complaint. 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 oversight and issue a complaint response within 2 weeks.

Mrs A complained that if her son, Mr B, had been appropriately scanned, assessed and investigated following his hospital admissions in July and August 2023, his brain tumour could have been detected earlier, allowing treatment to start sooner. The investigation specifically focused on whether Mr B’s clinical management between July and September 2023 was of an acceptable standard. The Ombudsman found that Mr B’s clinical management between July and September 2023 was of an acceptable standard and the complaint was not upheld. In relation to his ED attendance and admission in July, the Ombudsman found that the investigations carried out during Mr B’s ED attendance were appropriate based on his presentation and in line with national guidance. During his July admission, Mr B’s management was again in line with national guidance and of an acceptable clinical standard, as was the decision to request an outpatient MRI scan and neurology review. The Health Board had already accepted a shortcoming in that the outpatient MRI referral was not done. However, despite this, Mr B underwent a further MRI scan 4 weeks after he was discharged which was within the recommended timescales. In considering Mr B’s ED attendance in August and subsequent admission, while there was a short delay in ED triage, the Ombudsman found that this would not have altered Mr B’s management. In terms of his hospital admission, Mr B underwent a number of investigations and scans, and his management followed the key recommendations outlined in national stroke guidelines. Furthermore, when a CT scan in August reported an intracranial hemorrhage with unclear cause, further scans were carried out to determine the cause of Mr B’s hemorrhage, which was clinically appropriate, as was the plan to arrange a follow-up scan in 3 months.

Mrs C complained about whether the standard of care provided to her mother, Mrs B, for the management of her cataract (when the lens in the eye develops a cloudy patch) to her right eye was clinically appropriate and timely. The investigation found that Hywel Dda University Health Board (“the Health Board”) did not respond appropriately to advice it requested from a Second Health Board regarding Mrs B’s care. During the COVID-19 pandemic when public health measures which were put in place to prevent the spread of infection I have seen no evidence that the Health Board considered guidance in place at the time to assess the risk this would cause to Mrs B. When Mrs B was seen again, following the easing of these measures, the review she underwent was inadequate. Relevant tests were not undertaken, a letter to her GP regarding medication was insufficiently detailed and an opportunity was missed to make an earlier referral for further treatment. During the period of time under investigation Mrs B experienced numerous cancelled clinic appointments. These are significant service failings. Mrs B, who is blind in her left eye, is now also significantly sight impaired in her right eye. Mrs C has described the devastating impact this has had on both Mrs B and her wider family. I also consider that the failures in this case are ones from which other health boards can learn. I have seen no evidence the Health Board assessed the potential harm to Mrs B when cancelling clinic appointments. Earlier opportunities to identify the seriousness of Mrs B’s condition, and to refer her for further treatment, were also missed. The Ombudsman made a number of recommendations which the Health Board accepted: Within 1 month: a) Apologise to Mrs B and Mrs C for the failings identified in this report. b) Offer Mrs B financial redress in the sum of £4,500 reflecting the serious failings I have found and the resulting and lasting significant impact upon her. To further offer Mrs B redress of £300 f

Miss C complained about the care and treatment provided to her by Cardiff and Vale University Health Board in its management of her early pregnancy loss. The Ombudsman found that the Health Board’s complaint response to Miss C was not compliant with The National Health Service (Concerns, Complaints and Redress Arrangements) (Wales) Regulations 2011. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to apologise to Miss C and to provide confirmation that her complaint would be fully investigated with in accordance with the Regulations, within 5 days.

Mrs A complained about the care and treatment provided to her late husband by Betsi Cadwaladr University Health Board. Mrs A was dissatisfied with the Health Board’s response to her complaint. The Ombudsman found that, although the Health Board had investigated Mrs A’s concerns, the complaint response had not adequately addressed matters for her. Mrs A was inconvenienced by the Health Board’s actions and this has caused frustration for her. The Ombudsman decided to settle the complaint without an investigation. The Health Board agreed to, within 4 weeks, contact Mrs A to arrange a meeting, between Mrs A and relevant staff, to discuss the outstanding concerns and to provide a further complaint response within 16 weeks

Mrs A complained about the care and treatment provided by Cardiff and Vale University Health Board following a colposcopy in January 2025. Results were not available for 10 weeks, which led to a delay in diagnosis and treatment for cervical cancer. Mrs A also complained that she had previously been discharged in 2021, with a 3-year recall, and raised concerns about a biopsy and sampling. The Ombudsman found that although the Health Board had investigated Mrs A’s concerns, she had not received an adequate response to her initial complaint or the matters raised subsequently. Mrs A was inconvenienced by the Health Board’s actions, which caused uncertainty and frustration for her. The Ombudsman decided to settle the complaint without an investigation. The Health Board agreed to, within 6 weeks, reconsider Mrs A’s complaint and provide her with a further complaint response, addressing the additional matters raised with the Health Board and the Ombudsman.

Mr A complained that Cardiff Council failed to respond to his complaints that he submitted in October 2025. The Ombudsman found that the Council had responded to Mr A’s initial correspondence however it had overlooked his second complaint. The Ombudsman said that this caused uncertainty and frustration for Mr A. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Council’s agreement to, within 4 weeks, apologise for the delay and explain the reasons for it, issue its complaint response, and offer a £150 redress payment for the delay and in recognition of the time and trouble.

Mrs A complained that Swansea Council failed to respond to the complaint she submitted. The Ombudsman found that, while the Council had logged the complaint in April 2025 and provided discussion notes to Mrs A, it did not provide a formal complaint 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 4 weeks, offer an apology to Mrs A for the oversight in not providing a formal complaint response and explain why this happened, issue a formal complaint response and offer a £100 financial redress payment in recognition of the time and trouble.

Mrs B complained about the discharge planning in respect of her daughter, Miss A. The investigation considered whether the discharge planning prior to Miss A’s discharge on 23 January 2023 was appropriate and met her needs. The investigation specifically considered whether an updated risk assessment and care and treatment plan (“CTP”) were required prior to discharge and whether there were controlled measures in place to ensure mitigation of the risks identified. Miss A had been re-admitted to hospital on 21 January 2023 following an overdose. The planning in the lead up to her previous discharge in December 2022 was clinically appropriate. The Wales Applied Risk Research Network (“WARRN”) formulation-based assessment and CTP undertaken on 22 December was comprehensive, extensive and in line with national guidance. These assessments and plans were of a high standard. The WARRN was updated on 2 occasions during the appropriately short re-admission in January. Whilst the CTP was not updated by the Community Mental Health Team (“CMHT”) prior to discharge, the December 2022 version of the CTP covered a wide range of scenarios and recommendations on how to deal with them. There was a risk that Miss A would attempt to self-harm post discharge. However, a certain degree of risk is commonly accepted to allow patients to live in the community and avoid long term hospital admission. The management plan to mitigate the risk of self-harm/suicide by locking Miss A’s medication in a cabinet was clinically appropriate and in line with national guidance. Unfortunately, the medication cabinet was not robust enough to withstand force, but this was not the fault of the Health Board. The complaint was not upheld.

Mr A complained about the care and treatment provided to him by the Health Board from March to September 2024 and about the response to his complaint. The Ombudsman found that, although the Health Board had responded to Mr A’s complaint, it had not provided him with clear information regarding communication tools available to support patients. The Ombudsman 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 Mr A with an explanation and information about available communication tools, such as the patient passport, to support patients when accessing healthcare. The Health Board agreed to do this within 4 weeks.