PSOW Individual Decisions

Ms A complained that the Health Board’s complaint response failed to address all her points, lacked detail and explanation and did not inform her of the next steps regarding her treatment. The Ombudsman found that the complaint response lacked detail. The Ombudsman said this left Ms A with many unanswered questions and decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to within 30 working days issue a further complaint response addressing and explaining the points Ms A raised.

Ms A complained that Monmouthshire County Council failed to respond to a complaint she raised concerning a 4 year road closure due to a collapsed wall. The Ombudsman found that the Council missed the formal complaint which caused additional frustration and uncertainty for Ms A. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought the Council’s agreement to write to Ms A within one week to apologise for missing the formal complaint. It also agreed to issue its complaint response within four weeks.

Dr B complained that Aneurin Bevan University Health Board failed to issue a response to her complaint, which she submitted in April 2025, regarding the care and treatment provided to her late brother. The Ombudsman found that the Health Board had failed to issue a complaint response. She said this caused frustration and uncertainty to Dr B and decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to apologise and provide an explanation to Dr B for the delay, issue a complaint response, and offer a redress payment of £150 in recognition of the delays she has experienced.

Mr C made a complaint on behalf of his brother, Mr B, about whether Cardiff Council (“the Council”) acted in accordance with relevant legislation, policy and procedure (internal and external) and considered all information submitted when determining an application made for a Disabled Facilities Grant (“DFG”, a council grant that helps to meet the costs of adapting a disabled person’s home to improve their independence) on behalf of Mr B. The investigation found that the Council had acted in accordance with its Adaptions Criteria and Guidance and considered all information submitted when determining an application made for a DFG on behalf of Mr B. The Ombudsman did not uphold this complaint.

Ms A complained about the care and treatment provided to her husband, in particular from the Cardiology team. The assessment found that the Complainant had requested an explanatory meeting with treating clinicians, but that this was yet to be arranged. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to, within 2 months, arrange a meeting with Ms A, her advocate and relevant clinicians to allow an opportunity for discussion further to the complaint response.

Ms C complained about the care and treatment provided to her late mother, Mrs B, by the Health Board following hip replacement surgery in December 2023. The investigation considered whether it was clinically appropriate for Mrs B to have a general anaesthetic for her surgery, and whether it was clinically appropriate for Mrs B to have been discharged from hospital following her surgery on 4 January 2024. It also considered whether it was clinically appropriate for Mrs B to have been subsequently discharged from the Emergency Department (“ED”) on 13 February 2024 and 20 February 2024. The Ombudsman found that the choice of general anaesthetic for Mrs B’s hip surgery was appropriate and in line with accepted good clinical practice. Furthermore, given Mrs B’s condition, it was reasonable to have discharged her on 4 January 2024. Those complaints were not upheld. However, Mrs B was discharged from the ED on 13 February without pneumonia being reasonably explored and diagnosed, and she was therefore discharged without appropriate treatment at that time. That was a service failure and an injustice to her. The Ombudsman upheld this aspect of the complaint. When Mrs B was re-admitted on 19 February with the same symptoms, it was recognised that she had pneumonia, appropriate treatment commenced and her discharge from the ED on 20 February was reasonable. The Ombudsman did not uphold that part of the complaint. The Health Board agreed to the Ombudsman’s recommendations to provide Ms C with an apology for the failings identified; to review this case in relation to the clinical investigations carried out for Mrs B between 10-13 February 2024 to identify any points of learning which can be applied in future care, and to ensure, as part of a reflective process, that the General Medical Consultant responsible for discharge on 13 February shares details of this case and the Ombudsman’s report at their annual appraisal.

Mr A complained about the Council’s decision to reject his request for post-16 additional learning needs (“ALN”) transport for his daughter. The Ombudsman considered that the eligibility criteria which the Council had applied was not available to the public at the time of the request, or contained within its policy. She also considered that the Council had made no true assessment of Mr A’s daughter, and had restricted its discretion by applying this criteria. The Ombudsman sought and gained the Council’s agreement to, within 4 weeks, make a full assessment of Mr A’s daughter’s circumstances and re-consider the request, and to review its eligibility criteria. Further, within 8 weeks, to undertake a review of all applications within the last 12 months to identify any decisions where the same criteria was applied, and agree to re-consider any applications identified.

Mr A complained about Neath Port Talbot Council’s handling of his complaint regarding its failure to issue an amended Individual Development Plan (“IDP”) for his son, within the statutory timelines. The Ombudsman decided that whilst the Council had issued a Stage 2 response, it was brief and did not sufficiently address the complaints raised, or consider the remedies sought. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Council’s agreement that within 2 weeks it would contact Mr A to agree the outstanding elements of his complaint and clarify the remedies sought; and within 1 month of contact it would respond to the complaint.

Mr A complained about Cardiff Council’s handling of concerns about parking and enforcement issues. Mr A complained to the Council about repeated misuse of the public highway and pavement outside his home, but had not received a complaint response. The Ombudsman found that the Council had not provided a response to Mr A’s complaint. Mr A was inconvenienced by the Council’s failure to respond to his concerns, which caused him stress, uncertainty and frustration. The Ombudsman decided to settle the complaint without investigation. The Ombudsman sought and gained the Council’s agreement to, within 4 weeks, provide Mr A with a written response to his complaints, together with a written apology for the failure to address his concerns.

Complaint about the action taken by the Council about provision of school transport and social care services for her children. She also raised concerns that the Council had not agreed to investigate her complaints. ER agreed for the Council to: investigate Mrs A’s complaint about the decisions made by the Council regarding school transport provision for her children and about ongoing delays with the provision of social care services. It agreed to provide a full response to Mrs A, outlining action taken by the Council in line with relevant policies. The Council agreed to confirm to Mrs A the current options available for support with transport and the current status of any options for social care support available for both children. The Council agreed to complete these actions within 4 weeks.

Mr C complained that Cardiff and Vale University Health Board did not communicate appropriately with him and his family in the final hours of his brother’s life, or following his brother’s death. The Ombudsman decided that the Health Board had not addressed all of Mr C’s concerns in its complaint response. The Ombudsman noted that the Health Board had offered to meet with Mr C. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to contact Mr C within two weeks, to agree whether to respond to the remaining concerns in a meeting or in writing, and to provide a response within four weeks of the agreement.

Miss A complained to the Practice in June 2025regarding the treatment she received. The Ombudsman found that, while the Practice had consultations with Miss A to address the concerns, it had not responded inwriting via the complaints procedure. The Ombudsman said this caused uncertainty and frustration for Miss A and decided to settle the complaint without an investigation. The Ombudsman sought and gained the Practice’s agreement to, within 3 weeks, provide the complaint response in writing and apologise and explain for not addressing the concerns via the complaint procedure.

Mr B complained about the care and treatment he received from the Health Board for prostate cancer. Specifically, whether his clinical management and communication between July 2024, when he was referred to hospital, and 3 February 2025 when chemotherapy treatment commenced, was appropriate, timely and in keeping with relevant guidance. The Ombudsman found that Mr B’s clinical management and the way the Health Board communicated with him was not appropriate. There were avoidable delays in Mr B’s treatment which was not in keeping with relevant guidance. Mr B was also not provided with some relevant information, which meant he was unable to make informed decisions about his care. Mr B’s complaint was upheld. The Ombudsman sought and gained the Health Board’s agreement to apologise to Mr B for these failings. The Health Board also agreed to share the investigation report with the clinicians involved in Mr B’s care so that the findings could be considered and discussed and to review the way it collects and shares information on estimated waiting times for oncology referrals.

Mr B complained that the Health Board failed to diagnose his father, Mr A’s, bladder cancer in a timely manner following referral from his GP on 19 July 2023. The investigation found delays in the diagnosis and treatment of Mr A’s bladder cancer and that failures occurred. However, it also found that it was unlikely Mr A’s sad outcome would have differed if care and treatment had been more timely, due to the aggressive nature of his cancer. Nevertheless, it found that Mr A suffered an injustice as he lost the chance to receive certainty about his condition and be provided with palliative care sooner. This complaint was therefore upheld. The Health Board agreed to carry out the Ombudsman’s recommendations to apologise to Mr B, and to introduce a tracker of referrals of patients with suspected cancer to ensure delays are visible. It also agreed to conduct an audit of all patients who are under suspicion of malignancy and are awaiting 2 combined procedures or more to assess whether both procedures are necessary to diagnose malignancy. If not, the necessary diagnostic procedure should be arranged and undertaken in isolation if this would ensure a timelier investigation for diagnosis of malignancy.

Mr A complained about the orthopaedic management and care he received at Betsi Cadwaladr University Health Board’s Ysbyty Glan Clwyd. Specifically, Mr A’s complaint centred on the appropriateness of the decision to refer him for specialist intervention in 2023 for a non-healing fractured femur (thigh bone) and for him to limit weight-bearing on that leg. Mr A was concerned that this delayed physiotherapy input and his recovery. The Ombudsman’s investigation concluded that it was clinically appropriate for Mr A to be partially weight-bearing (“PWB”) on that leg between August and October 2023, given there were areas where Mr A’s femur was not healing. However, the Ombudsman identified that an updated X-ray should have been carried out before the decision to make a specialist referral and for Mr A to continue PWB was made in the December. Had this happened, X-rays might have shown that Mr A’s femur was healing and therefore prompted a change in his PWB status. The investigation identified that during the significant time (December 2023 to May 2024) that Mr A remained PWB, there were inadequacies both in monitoring and progressing the specialist referral and in follow-up clinic reviews. Mr A will have to live with the uncertainty of not knowing whether the degree of physiotherapy input that would have assisted his recovery could have happened sooner. This is an injustice to him. It was to this extent that Mr A’s complaint was upheld. The Health Board agreed to carry out a number of recommendations. These centred on apologising to Mr A, clinician learning through the sharing of this report, and in terms of onward specialist referrals, that it review and evidence to this office that there are effective mechanisms in place for clinicians to monitor and to check progress on these referrals, or provide an action plan setting out how this will be achieved.

Mr A complained that Cardiff Council failed to address the concerns he raised regarding his glass bin collection. The Ombudsman found that, while the Council had provided a complaint response, it did not provide an explanation to Mr A. The Ombudsman said this caused uncertainty and frustration for Mr A and decided to settle the complaint without an investigation. The Ombudsman sought and gained the Council’s agreement to, within 2 weeks, write to Mr A to provide reassurance and outline the steps the Council is taking to monitor the situation.

Mr A complained that Aneurin Bevan University Health Board improperly removed him from its ENT waiting list, stating that he had not contacted it when he had. The Ombudsman found that Mr A had followed the advice in the Health Board’s letter and had emailed it regarding an ENT appointment. Despite this, the Health Board had incorrectly removed Mr A from the ENT waiting list. The Ombudsman said this caused Mr A uncertainty and frustration and she decided to settle the complaint without a formal investigation. The Ombudsman sought and gained the Health Board’s agreement to apologise to Mr A for incorrectly removing him from the waiting list, to confirm in writing to Mr A that he had been reinstated on the waiting list in the same position he would have been in had he not been incorrectly removed, and to explain to Mr A what went wrong within 2 weeks.

Mrs A complained that Betsi Cadwaladr University Health Board failed to address the concerns she raised regarding the hysterectomy. The Ombudsman found that, while the Health Board had been in discussion with Mrs A regarding her concerns, it had failed to provide her 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 and provide an apology and explanation for not addressing the concerns via the Putting Things Right complaint procedure.

Miss A complained that Powys Teaching Health Board (“the Health Board”) failed to provide a patient specific complaint response in relation to the management of her late father’s care and treatment. The Ombudsman found that the Health Board failed to adequately address Miss A’s concerns in relation to the rationale behind abrupt medication changes and whether the inappropriate management of medication caused over sedation. The Ombudsman sought and gained the agreement of the Health Board to provide Miss A with a further complaint response within 1 month.

Mrs A complained that Caerphilly County Borough Council (“the Council”) failed to provide her with information about homecare charges and was delayed in commencing the financial assessment, which resulted in a large and unexpected cost for care fees. The Ombudsman found that the Council had failed to provide relevant written guidance when homecare services commenced and did not provide a reminder or written confirmation when a second episode of care commenced. The Council did not request details to inform a contributions letter nor a letter advising of the cost of her homecare contribution until over a year after the care had commenced. The Council has also not addressed what steps have been taken to improve communication. The Ombudsman considered that the failure to provide information and the sustained period of poor/delayed communication by the Council resulted in a significant balance accruing which had an unexpected financial impact. The Ombudsman sought and gained the Council’s agreement to reduce the owed care fees by £500, agree to a flexible repayment plan for the remainder of the fees, complete a review of internal processes to improve communication and write to Mrs A to set out what was identified and what steps have been taken to improve communication processes.

Mrs A complained regarding the construction of a garage near her property. The Ombudsman found that the Council had not fully responded to the concerns raised and 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 Council’s agreement to, within 2 weeks, write to the complainant to clarify the point Mrs A has raised and provide information on how to report a new planning breach following the completion of the build.

Ms A complained about the care and treatment her father received from Hywel Dda University Health Board when he was an inpatient in Withybush Hospital prior to his sad death in 2023. Ms A complained that her father was given a dry potassium tablet which should have been dissolved in water, and following this he became unwell. The Ombudsman acknowledged the Health Board’s position that the incident was not recorded in the medical records, and if it had occurred it would have been documented. However, it was also noted that Ms A had her own contemporaneous diary entries. The Ombudsman decided that whilst it was not possible to determine what had occurred, if the incident had taken place there was potential learning for the Health Board. She decided to settle the complaint without an investigation. Within 1 month, remind the staff on the ward of the importance of ensuring that the potassium tablets are administered with water and write to Ms A to inform her of this action.

Ms B complained about the care and treatment she received from Aneurin Bevan University Health Board in respect of its failure to examine her and delay in diagnosing a patella tendon rupture. The Ombudsman decided that the care and treatment provided was reasonable, and the Health Board’s complaint response was also reasonable. However, it was noted that Ms B had written to the Health Board again following receipt of the complaint response, and she had not received a further response. Whilst the Ombudsman considered that the Health Board had provided a reasonable response initially, it should have responded to Ms B to advise of this. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to, within 2 weeks, apologise to Ms B for not providing a response to her further letter.

Mr C complained that the Caerphilly County Borough Council had not taken appropriate action in response to safeguarding concerns he raised on behalf of his relative, Mr A. The Ombudsman decided that the Council had not handled Mr C’s complaints in accordance with its procedures. The Council had not properly considered Mr A’s wish for Mr C to act on his behalf, or his views on the complaint. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Council’s agreement to share the outcome of her consideration with the complaints team, to promote understanding regarding consent. The Council also agreed to provide feedback to Social Services to ensure that service users’ wishes are sought appropriately.

Mrs A complained that the Health Board had failed to respond to a complaint she had submitted to it over 6 months ago and this had impacted on her ongoing care needs. The Ombudsman found that the Health Board failed to investigate the complaint within the relevant timescale which caused additional frustration and uncertainty for Mrs A. The Ombudsman decided to settle the complaint without a formal investigation. The Ombudsman sought and gained the Health Board’s agreement to provide an explanation and apology to Mrs A for the delay in responding to the complaint and to issue its complaint response within 30 working days.