PSOW Individual Decisions

Miss B complained about the clinical care and treatment received by her partner, Mr A, at University Hospital of Wales (“the Hospital”). The investigation considered whether the delay in commencing suitable treatment for Mr A’s hepatitis B in September 2022 may have resulted in a detrimental impact on his health. The infection was identified following blood tests January 2021, but treatment was not considered until Mr A was formally told of the diagnosis in July 2022, some 17 months later. The Ombudsman found that Mr A already had chronic hepatitis B when he was tested in January 2021 and that this would have been present for more than 6 months, and likely many years prior to that. The delay in commencing treatment resulted in no detrimental or adverse impacts to Mr A’s health and any other symptoms experienced in the period of delay were unrelated. The complaint was not upheld.

Mrs Y was 69 years old and on 7 December 2021 she was admitted to hospital with abdominal pain, diarrhoea and vomiting. Mr S complained about Mrs Y’s treatment between 7 and 12 December 2021. The Ombudsman found that the delay Mrs Y faced in being placed on a ward was not detrimental to her as she had received ongoing care. She also found that it was unlikely that Mrs Y suffered a perforated bowel on 7 December, as a CT scan had not shown free air within the abdomen and her management was appropriate for the diagnosis of an uncomplicated diverticulitis. The Ombudsman found that on 11 December Mrs Y’s differential diagnosis included the possibility of a perforation, which led to further reviews and a CT scan that showed Mrs Y had experienced a perforation. It was found that this was the earliest opportunity to have identified the perforation, with no delay in its diagnosis. When consent was sought, Mrs Y was appropriately warned that the proposed procedure had a 43.3% risk of mortality. Mrs Y consented to a laparotomy for Hartmann’s procedure (to remove the diseased part of the large bowel to form a new opening for bowel contents), which she underwent on 12 December. The Ombudsman found that Mrs Y’s treatment between 7 and 12 December was appropriate and timely. Sadly, Mrs Y died on 26 December. The complaint was not upheld.

Ms A complained about the lack of recognition of her daughter, Child B’s needs, while she was in the paediatric intensive care unit (“the Unit”). Child B is severely disabled and non-verbal. The Health Board put forward settlement proposals which included carrying out a further review of Child B’s care, providing information about the facilities available to support families and benchmarking the Unit’s policy about parents staying overnight with their children while in intensive care against other Units. It also agreed to meet with the family following the review. The Health Board as part of the settlement, agreed to the Ombudsman’s proposal that one of its senior Learning Disability Champions should also be involved in the review of Child B’s care.

Mrs X complained about the standard of care and treatment provided to her late husband, Mr X, after he tested positive for COVID-19. Specifically, she complained that opportunities to treat him, as a vulnerable patient, with antiviral medication were missed. Mrs X was concerned that he should not have been initially discharged from the Grange University Hospital and that additional treatment should have been given to him for COVID-19. She complained that he was prescribed antibiotics by the GP following a telephone consultation as opposed being seen by the GP. When Mr X was later admitted to the University Hospital of Wales with COVID-19 symptoms, Mrs X felt that the provision of antiviral treatment was delayed. The Ombudsman found that the decision to discharge Mr X from the Grange University Hospital was reasonable as Mr X had not required any specific hospital treatment for COVID-19 at that point. His condition had not met the national criteria for prescribing antiviral medication. On admission to the University Hospital of Wales, Mr X’s condition had deteriorated, and he was assessed as needing the antiviral treatment. This was prescribed within an appropriate timescale. The prescribing of antibiotics by the GP was appropriate as it was based on a detailed history and telephone assessment of Mr X’s presenting symptoms. The Ombudsman found no failings in the care provided and did not uphold the complaints.

Dr B complained about the care and treatment she received from Cardiff and Vale University Health Board (“the Health Board”) before, during and after the birth of her first child on 1 March 2021. The investigation considered whether the available indications that Dr B’s baby was likely to be significantly larger than average were taken into sufficient account when planning and assisting her labour, and if more should have been done to start/progress her labour faster, including an induction and/or caesarean section. It also considered whether there were any indications that foreign material was left in Dr B’s uterus after the caesarean section, and if the complaint response provided by the Health Board was appropriate. The investigation found that, while Dr B’s labour was extended, the care and treatment provided to her was in line with relevant guidance. Although the material she had passed post birth was never conclusively identified, there was not sufficient evidence to find that it was likely to be due to foreign material left after the caesarean section. As a result, these elements of the complaint were not upheld. However, the investigation identified some issues in the complaint responses provided by the Health Board, and so this aspect of the complaint was upheld. The Ombudsman recommended that the Health Board should apologise to Dr B for the issues identified and remind the Clinical Board complaints handling staff of the importance of reviewing complaint responses to ensure consistency and accuracy.

Mr A complained that the clinical care and treatment received at a Cardiff and Vale University Health Board hospital emergency department was not to an appropriate standard. In particular, it failed to carry out a CT head scan, resulting in a missed opportunity to diagnose a transient ischemic attack (a temporary disruption to the blood supply to the brain causing a temporary lack of oxygen. Also known as a mini stroke). Based on the information seen and the advice received, it was found that the nature of the examinations and assessments carried out at the hospital were adequate. A CT scan was not indicated as being necessary, based on Mr A’s presenting symptoms and available medical history. The investigations and referral to an orthopaedic team were appropriate for the weakness in Mr A’s wrist that had prompted his attendance. I am satisfied that the care and treatment Mr A received, met an appropriate standard. Accordingly, the complaint was not upheld.

Ms A complained that the Neurologist’s clinic letter to the GP did not reflect accurately the telephone consultation that she had with him and the medication treatment plan that was agreed. She also complained about the accuracy of the Health Board’s complaint response when it came to aspects of the consultation. The Neurologist accepted that Ms A’s audio recording of the consultation was accurate. The Health Board agreed to the Ombudsman’s settlement proposal that it apologise to Ms A for the inaccuracies in its complaint response and that it remind clinicians of the need for accurate records of consultations with patients.

Ms A complained about neurological input into her treatment and care and the contents of some of the clinical letters that were sent by the Neurologist. The Ombudsman agreed a settlement in relation to part of Ms A’s complaint. The Ombudsman considered there was scope for the clinic letter that the Neurologist had sent to a referring clinician in January 2020 to have been more measured. She concluded that it was unhelpful that it strayed into clinical judgements that was outside of the Neurologist’s speciality by suggesting that the referring clinician cancel a referral to another specialism. It also contained inaccuracies as it said that Ms A was to be removed from the Neurology waiting list when clearly this did not happen. The Health Board agreed to apologise to Ms A again for the shortcomings in the Neurologist’s clinical letter. It also agreed to remind clinicians of the need for sensitivity when engaging in internal and external communication.

Mr T complained that Cardiff and Vale University Health Board failed to issue a written response explaining its findings and views to concerns she raised about the care and treatment provided to her late father. The Ombudsman found that the Health Board met with Mr T on two occasions to discuss the investigations but failed to follow up in writing. She said that this caused additional frustration and inconvenience to Mr T. The Ombudsman decided to settlement the complaint without an investigation and sought and gained the Health Board’s agreement to apologise for not providing a written response and to issue its response within 30 working days.

Mr B complained about the care and treatment he received when he attended the Emergency Department (“the ED”) at the University Hospital of Wales on 17 April 2022. Mr B complained that he was not appropriately assessed, appropriate scans were not undertaken, and he was discharged prematurely. He also complained that the complaint response he received from the Health Board was factually incorrect. Following commencement of the Ombudsman’s investigation, the Health Board reviewed Mr B’s care and its initial complaint response. It said, on review, the care provided to Mr B fell below a reasonable standard. It agreed to, within 4 weeks, apologise to Mr B and issue an updated complaint response, make a payment to Mr B of £1000 for the time and trouble in pursing this complaint, consider the case under its redress scheme with regard to a settlement for the additional pain and suffering experienced by Mr B due to the delay in a scan being undertaken, and share with the Ombudsman its updated guidance for investigation of Cauda Equina Syndrome (“CES”). It also agreed to, within 8 weeks, implement an additional clinical review process for all concerns regarding suspected CES injury, arrange for reviewing consultants in the ED to undertake awareness sessions regarding the recognition and investigation of CES, and share the case at the Clinical Board Quality Safety and Experience meeting and the Morbidity and Mortality departmental meeting to promote discussion and learning. In light of these agreed actions the investigation was brought to a close.

Ms A’s complaint related to the care and treatment that her late partner, Mr B, received from the Health Board and the Trust in 2020. Specifically, Ms A complained that there had been a delay in the Health Board confirming her partner’s diagnosis of lung cancer with a biopsy, and that both the Health Board and the Trust then failed to start his treatment immediately after this diagnosis was confirmed in September 2020. Following Mr B’s admission to hospital in October 2020, Ms A complained that a Do Not Attempt Cardiopulmonary Resuscitation (“DNACPR”) form was inappropriately placed on her partner’s records and that the Health Board failed to provide him with appropriate care and treatment during the admission. Furthermore, Ms A raised concerns that she was denied the opportunity to visit Mr B before he died, despite being informed that he was “critically ill” and numerous family members then being allowed onto the ward after his death, and that the Health Board failed to provide her with regular updates on Mr B’s condition and did not contact her to inform her of his death. In addition, Ms A also raised concerns that her partner’s basic hygiene needs were ignored given that he died in the same clothes that he was admitted to hospital in 2 days beforehand. Ms A also complained about the accuracy and completeness of the Health Board’s complaint response. The Ombudsman concluded that although there were delays in confirming Mr B’s diagnosis with a biopsy, these delays were not due to any identifiable failings on the part of the Health Board and appropriate investigations into Mr B’s lung cancer had been undertaken in accordance with relevant guidelines. The Ombudsman also considered that the length of time between the confirmation of Mr B’s diagnosis and the proposed start date for treatment had been reasonable under the circumstances. As a result, the Ombudsman did not uphold these complaints. In terms of Mr B’s later admission to the Hospital, the investigation foun

Mr W complained that Cardiff & Vale University Health Board had failed to address all of his concerns regarding the coordination of his care and treatment. He said that the Health Board had agreed to hold a meeting with him to discuss his outstanding concerns but he had not received a date. The Ombudsman found that there had been a delay by Health Board to arrange a meeting and this had caused inconvenience and frustration for Mr W. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to make arrangements to hold a meeting with Mr W within 4 weeks.

Miss X complained about her mental health care. She was unhappy after being discharged from secondary mental health services. A reassessment appointment further concluded that services could be provided via her GP. This assessment was online and she could hear other conversations in the background. She did not feel that it was confidential or in-depth. She was also unhappy about the manner in which her complaint was dealt with by the Health Board. The Ombudsman noted the concerns about the online assessment appointment, and the complaint response. We contacted the Health Board; it agreed to, within 20 working days: • To contact Ms X to arrange a mutually agreed time for a face-to-face mental health assessment with a psychiatrist to assess her current need for mental health services and support, in line with the provisions of the Measure, and whether she needs ongoing support from secondary mental health services. • To provide a written apology to Miss X for: a) the manner in which the online assessment was conducted b) the failure of the recording of the complaint meeting.

Miss B complained that Cardiff and Vale University Health Board failed to provide a response to her complaint about the care and treatment provided to her late father. The Ombudsman found that whilst the Health Board had issued a complaint response it had sent it to the incorrect email address. She said that this caused frustration and uncertainty to Miss B. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to apologise and provide an explanation for the failure, raise the matter with the relevant staff member to ensure that lessons are learnt and undertake the necessary checks to ensure that there has been no data breach. The Health Board also agreed to offer £50 redress to Miss B and to re-send the complaint response within 2 weeks.

Mrs A raised concerns in respect of her late husband, Mr A’s, care and treatment. Although the Health Board had provided Mrs A with a response, she did not accept some of the explanations given. She complained there were still outstanding concerns around Mr A not being fit for surgery, discrepancy around being transferred to the Intensive Care Unit and diagnosis. The Ombudsman was concerned to note Mrs A’s outstanding concerns and felt it would be helpful for her outstanding questions to be addressed. As an alternative to investigating the complaint, the Ombudsman made recommendations which the Health Board agreed to implement. The Health Board agreed to convene a meeting with Mrs A and her Complaints Advocate in attendance. Thus contact would be made via her Complaints Advocate within 15 working days to start discussions about the necessary arrangements.

Mr X complained that Cardiff and Vale University Health Board had failed to provide him with further surgery and had not issued a formal complaint response. The Ombudsman decided that the Health Board had failed to provide Mr X with a formal complaint response, which caused frustration to Mr X and led him to contact the Ombudsman. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to issue its formal complaint response within 2 weeks.

Miss A complained to Cardiff and Vale University Health Board (“the Health Board”) about the failure to communicate the results of genetic testing to her local Health Board. She also complained about the fact that she had contacted its Patient Advice and Liaison Service (“PALS”) team about this issue on numerous occasions, but no one returned her calls. The Ombudsman found that the Health Board had sent Miss A’s test results to her local Health Board via post. She considered that there may be a more reliable, expedient and secure way of electronically communicating test results. Further, she found that Miss A’s complaint submission to the Health Board did not specifically reference her contact attempts being made with the PALS team, and so this may not have been clear to the Health Board when investigating her complaint. The Ombudsman contacted the Health Board. In respect of the communication of test results, it confirmed that a new information management system had already been purchased, and was in the process of being implemented, meaning that genetic reports would be shared seamlessly and instantaneously with other clinical systems across Wales. The Ombudsman was satisfied with this, and did not feel further intervention was required. In respect of Miss A’s contact with the PALS team, the Health Board agreed to provide a further written response to her, specifically addressing this issue, within 20 working days.

Mr A complained to Aneurin Bevan University Health Board (“the Health Board”) about care and treatment provided to his late wife, Mrs A, by it, Cardiff and Vale University Health Board (“CAVUHB”) and Welsh Ambulance Service NHS Trust (“WAST”). Mr A complained to the Ombudsman that following the Health Board’s response, he had not received answers to all of the questions he raised. The Ombudsman found that the Health Board took the lead in terms of co-ordinating a joint investigation/response to Mr A, in conjunction with CAVUHB and WAST. However, not all of Mr A’s concerns about CAVUHB had been addressed and he had not received any response at all from WAST. Whilst the Health Board explained that WAST normally issue a separate complaint response, there was still a duty on it to ensure that Mr A received a co-ordinated response to his complaint, which the Health Board had failed to do. In resolution of Mr A’s complaint, the Health Board agreed to, within 30 working days, provide him with a written apology for the failure to provide a co-ordinated response, which addressed all aspects of his complaint and also to provide a further written response to Mr A which addressed all aspects of his complaint, including those relating to care and treatment provided by CAVUHB and WAST.

Mr S complained that Cardiff and Vale University Health Board failed to pick up a referral for his father. Mr S said that it was only discovered when he contacted the Health Board for an update and an explanation as to why it was missed was not provided. The Ombudsman found that the Health Board had responded to Mr S’ communication but it had failed to do so in line with the complaint process. She said this caused additional frustration and inconvenience to Mr S and his father as it missed an opportunity to investigate and provide a meaningful response. The Ombudsman decided to settle the complaint without an investigation. She sought the Health Board’s agreement to investigate the complaint and issue a response, including general time scales for waiting lists, within two months.

Ms L complained that Cardiff and Vale University Health Board failed to provide her with the help and support she required. She further complained that despite raising a complaint in January 2023, she had not yet received a response. The Ombudsman concluded that the Health Board failed to keep Ms L updated with its investigation, and further failed to respond in a timely manner. She said this caused frustration to Ms L. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to provide Ms L with an apology for the delays and issue a formal response within 6 weeks.

Mrs D complained that the laparoscopic cholecystectomy (gall bladder removal) she underwent on 13 September 2021 was not carried out to an appropriate standard. This meant that Mrs D needed a further operation at a later date; however, she was informed surgery went smoothly. Mrs D also complained that her request for additional support from the First Surgeon following her second surgery was ignored. Mrs D subsequently decided to pursue an Alternative Legal Remedy and so the Ombudsman’s investigation into her complaint was discontinued. As no findings were made, the Ombudsman did not make any recommendations regarding this complaint.

Miss L complained that despite raising several complaints about her misdiagnosis, she had not received a formal response from Cardiff and Vale University Health Board. The Ombudsman found that although the Health Board had contacted Miss L via telephone and post, it had not formally responded to her concerns in line with its statutory complaint’s procedure. She said this caused frustration to Miss L. As an alternative to an investigation, the Ombudsman sought and gained the Health Board’s agreement to provide Miss L with an apology for the delay in responding and issue a formal response within 6 weeks.

Miss X complained about the alleged change to her son’s placement who is currently a patient at an assessment and treatment unit for learning disabilities under section 3. Miss X alleges that the change in placement may not meet his care and treatment needs. The Ombudsman decided that due to ongoing concerns, there was a need for the Health Board to provide a further complaint response. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to issue its further complaint response to detail the steps it has taken in relation to the placement within 2 weeks.

Mr A complained to Cardiff and Vale University Health Board about care and treatment provided to him during his admission to its Emergency Department in September 2022. The Ombudsman found that although the Health Board had provided a satisfactory response to the majority of the concerns raised by Mr A, there were 2 issues raised which the Health Board had not provided a satisfactory response to. The Ombudsman contacted the Health Board and in resolution of Mr A’s complaint it agreed to provide a further written response to him, specifically addressing the 2 outstanding matters, within 20 working days.

Ms Z complained about the care and treatment she received, between 1 July and 5 July 2021, from Cardiff and Vale University Health Board. Ms Z said the Health Board failed to perform her appendectomy within an appropriate time frame. Following the operation, Ms Z said she was not appropriately monitored and prompt action was not taken to address her raised temperature and blood test results. Finally, Ms Z said she was not provided adequate discharge information and follow-up arrangements. The Ombudsman found that Ms Z had her appendectomy surgery within an appropriate timeframe based on her clinical presentation. Following her surgery, Ms Z was monitored, and appropriate action taken in regard to her blood culture results and when her temperature was raised. It was also found that appropriate discharge plans were in place. Ms Z’s complaint was therefore not upheld.