PSOW Individual Decisions

We investigated a complaint from Mr A about his grandmother, Mrs B’s, hospital care in January 2024. The investigation specifically focused on whether the accepted lack of observations following Mrs B’s admission to hospital significantly impacted her condition, and whether communication with Mr A, his father (Mr C) and his grandfather (Mr F) by staff at the Hospital was appropriate, prior to, and following, the death of Mrs B. The investigation found that Mrs B received an appropriate level of clinical care given the challenges of treating her in light of the presence of multiple health conditions. However, there was a lack of action or escalation of care when her NEWS (a system to identify deterioration in a patient) was raised, which was contrary to expected practice. This was a service failure. However, the lack of observations/escalation did not significantly impact on Mrs B’s condition and did not contribute to her deterioration or death. This complaint was not upheld. The investigation found that communication with Mr A, Mr C and Mr F during Mrs B’s admission fell short of expected standards. The standard of communication following Mrs B’s death was also of concern. Despite telling Mr A in its complaint response that Mrs B expressed a preference for her sister to be contacted as opposed to her husband (who was the documented next of kin) and son, there were no corresponding entries in Mrs B’s records to support this, which was contrary to expected practice. This lack of contemporaneous records was contrary to the requirements of expected nursing standards. This amounted to maladministration and meant there was an inappropriate delay in informing Mr A, Mr C and Mr F about her poor prognosis and death. As a result, it is likely that they missed an opportunity to see Mrs B before she died. This was an injustice and this complaint was upheld. The Health Board agreed to apologise to the family for the serious communication shortcomings and to acknowledge the impac

Miss A was dissatisfied with the handling of her complaint that Welsh Government’s Nest Scheme failed to register her boiler when it was installed. Miss A had to chase a response to her emails, and she said that her telephone calls were never returned. The Ombudsman decided that unreasonable delays had occurred in replying to Miss A’s correspondence, and her concerns had not been investigated or responded to as a formal complaint. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained Welsh Government’s agreement within 2 weeks, to offer Miss A an apology, and to investigate her concerns, remedying any issues identified.

Miss A complained that the Health Board had not responded to all the concerns that she had raised. At assessment, the Ombudsman found that the Health Board had not responded to all of Miss A’s concerns. The Health Board agreed, within 4 weeks, to provide a further response that covers the concerns that had not been responded to.

Miss A complained to Barcud about the ongoing disrepair issues in her property. She said Barcud had failed to act on jobs she had reported. The Ombudsman found that Barcud had not fully addressed the disrepairs in Miss A’s property. The Ombudsman considered that this caused Miss A frustration, as problems remained unresolved, and decided to settle the complaint without an investigation. The Ombudsman gained Barcud’s agreement to within 4 weeks, organise a site visit with appropriately qualified people to record the repairs Miss A was seeking, within 1 week of the site visit write a letter to Miss A listing the repairs she sought along with a clear explanation as to the rationale for accepting or rejecting each one and within 4 weeks of that letter write to Miss A, setting out timescales of when it proposed to do the work.

Mrs A complained that Aneurin Bevan University Health Board failed to respond to her letter dated 15 November 2025 in which she was seeking clarification on the complaint response she had received. The Ombudsman found that the Health Board failed to respond to Mrs A. The Ombudsman said this caused additional frustration and uncertainty for Mrs A and decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to, within 2 weeks, write to Mrs A with a response to her letter which should also include an apology for not responding.

Miss A complained about the care and treatment that her mother, C, received from the Health Board prior to her death. The Ombudsman considered that, as the complaint had been made prior to the death of C and HM Coroner’s Inquest, the Health Board had not considered Miss A’s specific concerns relating to her mother’s death. The Ombudsman sought and gained the Health Board’s agreement to, within 4 weeks, reconsider the care and treatment provided to C in light of her death, and the findings of HM Coroner, and provide a response to Miss A which reconsiders her original questions, and her view that the failure to correctly assess C resulted in her death.

Mrs A complained that Cwm Taf Morgannwg University Health Board had refused to arrange a meeting with her following its complaint response. The Ombudsman was concerned that the Health Board had refused a meeting despite offering to meet with Mrs A if it had not addressed her complaint to her satisfaction. The Ombudsman said this cause 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 reconsider its decision to meet with Mrs A and to arrange a meeting within 8 weeks.

Mr B, who lives on a Gypsy and Traveller site (“the Site”), complained that his pitch was overcrowded, there was a failure by Cardiff Council to maintain his utility block, and there was difficulty in purchasing electricity. During the investigation of Mr B’s complaint, concerns were identified about how the Council had managed the whole of the Site. The Ombudsman’s Own Initiative powers were used, which allow for an investigation to be extended when related issues are identified during a current investigation, to extend the investigation. The extended investigation examined whether the Council had complied with its legal duties in relation to the Site, whether there had been service failure or maladministration in relation to the Council’s maintenance of the utility blocks on the Site, and whether there had been maladministration or service failure in relation to the management of the residents’ electricity supply on the Site. The investigation found that the facilities in place on Mr B’s pitch were not appropriate given the number of residents and needs of the individuals. The investigation also found that there had been a failure to maintain Mr B’s utility block. The ability to purchase electricity was considered as part of the extended investigation. In respect of the extended investigation, it was found that there was a longstanding issue with demand exceeding availability of pitches in this area. This had been impacted by a number of factors, including the area on which the Site sits being previously deemed unsustainable which impacted the Council’s ability to secure funding for redevelopment. Significant progress is now being made in this regard, with a Shore Protection Scheme underway which has changed the status of the Site. The Council has also progressed the purchase of additional land as part of a plan to expand and develop the Site. However, the investigation found that, although the Council had undertaken a significant amount of complex work to progres

Mr A complained that Cardiff Council failed to respond to the complaint he submitted in July 2025. The Ombudsman found that the Council had failed to provide a formal complaint response to Mr A and 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, provide the complaint response, apologise for the delay and explain why this happened, and offer a £50 financial redress payment in recognition of the delays.

Mr B, who lives on a Gypsy and Traveller site (“the Site”), complained that his pitch was overcrowded, there was a failure by Cardiff Council to maintain his utility block, and there was difficulty in purchasing electricity. During the investigation of Mr B’s complaint, concerns were identified about how the Council had managed the whole of the Site. The Ombudsman’s Own Initiative powers were used, which allow for an investigation to be extended when related issues are identified during a current investigation, to extend the investigation. The extended investigation examined whether the Council had complied with its legal duties in relation to the Site, whether there had been service failure or maladministration in relation to the Council’s maintenance of the utility blocks on the Site, and whether there had been maladministration or service failure in relation to the management of the residents’ electricity supply on the Site. The investigation found that the facilities in place on Mr B’s pitch were not appropriate given the number of residents and needs of the individuals. The investigation also found that there had been a failure to maintain Mr B’s utility block. The ability to purchase electricity was considered as part of the extended investigation. In respect of the extended investigation, it was found that there was a longstanding issue with demand exceeding availability of pitches in this area. This had been impacted by a number of factors, including the area on which the Site sits being previously deemed unsustainable which impacted the Council’s ability to secure funding for redevelopment. Significant progress is now being made in this regard, with a Shore Protection Scheme underway which has changed the status of the Site. The Council has also progressed the purchase of additional land as part of a plan to expand and develop the Site. However, the investigation found that, although the Council had undertaken a significant amount of complex work to progres

Mr C complained about the care that Betsi Cadwaladr University Health Board provided to his grandmother, Mrs X. He disputed some of the information in the Health Board’s response and complained that there was insufficient evidence of learning. The Ombudsman decided that the Health Board’s complaint response had not adequately addressed the concerns raised by Mr C. The response did not fully reflect the information in Mrs X’s clinical records. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to write to Mr C within two months to address the concerns and describe any further action to be taken.

Ms B complained that Cwm Taf Morgannwg University Health Board failed to provide the final response that it agreed to provide following Ms B raising further concerns and questions. The Ombudsman found that the Health Board agreed in July 2025 to issue a further response and provided an anticipated timescale, however, it failed to provide this final response. The Ombudsman said this caused uncertainty and frustration for Ms B and she decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to, within 20 weeks, provide the final response, apologise for the significant delays and explain why this happened and offer a £200 financial redress payment in recognition of the delays.

Mr A complained that he had not received a response from Hywel Dda University Health Board to a complaint he made in February 2025 about a head injury. The Ombudsman found that the Health Board had not provided Mr A with a final complaint response. 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 Health Board’s agreement to provide the final complaint response that will include an apology and explanation for the delays. The Health Board agreed to do this within 4 weeks of the Ombudsman’s decision.

Mr A complained about Cardiff Council’s response to his complaint about his council tax payment plan. The Ombudsman found that following Mr A’s email about his concerns, the Council failed to provide him with information on how to submit a formal complaint or to log and respond to his concerns under its complaints process. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Council’s agreement to apologise to Mr A for not addressing his concerns via the Council’s Corporate Comments, Complaints and Compliments Policy and to issue a complaint response. The Council agreed to do this within 4 weeks of the Ombudsman’s decision.

Ms A complained that Aneurin Bevan University Health Board had failed to respond to her complaint or update her regarding the care she received. The Ombudsman found that Ms A had complained to the Health Board 12 months ago and had still not received a formal complaint response. The Ombudsman considered that this caused Ms A to be left with unanswered questions and decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to issue a full complaint response which includes explaining the reasons and apologising for the delay to Ms A within 4 weeks.

Ms A complained that Trivallis (“the Housing Association”) failed to follow Safeguarding and Anti-Social Behaviour (“ASB”) procedures in response to the concerns she reported. She said that the Housing Association failed to respond to her correspondence within reasonable timeframes, or comply with its complaints policy. The Ombudsman decided that the Housing Association had responded appropriately to Ms A’s Safeguarding and ASB concerns. It had responded to the majority of Ms A’s complaints appropriately within reasonable timeframes, but there appeared to be some confusion when individual officers were unavailable, and some correspondence that had not been acknowledged or responded to. The Ombudsman acknowledged that this caused frustration for Ms A. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Housing Association’s agreement to provide a final response to Ms A to address any correspondence previously not responded to and to offer an apology for any delays. It agreed to provide clear details for reporting future concerns and timeframes to expect a response, and to review the use of out-of-office messages and a single point of contact, to ensure consistency in responding to correspondence when individual officers are unavailable. The Housing Association agreed to undertake the action within 2 weeks.

Ms A complained about the care and treatment she received from Powys Teaching Health Board (“the Health Board”) when a myofascial release (a type of technique used to help release tight muscle or soft tissue) was carried out during a physiotherapy appointment. Ms A said the myofascial release was carried out without her knowledge or consent and since the appointment she had experienced ongoing health issues. The Ombudsman found that although the Health Board had conducted an investigation, its complaint response was not adequate, as it did not fully address all Ms A’s concerns. The Health Board failed to do so again when Ms A highlighted the inadequacies in its response. Also, since the Health Board’s complaint response, there had been further appointments and investigations for Ms A’s symptoms, which included comment about the myofascial release and her ongoing symptoms. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to provide a further Putting Things Right response to Ms A, to include all concerns originally complained about, those raised in follow-up correspondence by Ms A, and further developments which may be of significance since the initial response, including appointments attended and investigations undertaken. The Health Board agreed to complete this within 8 weeks of the Ombudsman’s decision.

Mr A complained about the care that Cwm Taf Morgannwg University Health Board provided to his grandmother. He disputed some of the information in the Health Board’s responses and complained that there was insufficient evidence of learning. The Ombudsman decided that the Health Board’s complaint responses had not adequately addressed the concerns raised by Mr A. The responses did not fully reflect the information in Mr A’s grandmother’s clinical records. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to provide Mr A within 6 weeks, with a further response to his complaint, and an update on the learning action plan.

Mr A complained that Flintshire County Council (“the Council”) had not actioned Ms B’s request to escalate her complaint about care received by her father, Mr C, to stage 2 of the complaints procedure despite her request for escalation. The Ombudsman found that the Council had not followed it’s complaints procedure and had not actioned Ms B’s request for a stage 2 complaint investigation. The Ombudsman decided to settle the complaint without an investigation on the basis that within 2 weeks of issuing the decision the Council would: • Write to Ms B confirming that it has escalated her complaint to stage 2 of the Social Services complaint procedure and explain what will happen next.

Complaint that the Welsh Government had failed to take into account the safety of residents when implementing changes to the road and pavements where the complainant lives. ER agreed: The Ombudsman sought and gained the Welsh Government’s agreement to review the information provided by Mr A and reconsider if the complaint submitted falls within the scope of its complaints process. It agreed to provide Mr A with a formal response outlining the outcome of this review and an apology that he had not been informed of the decision not to consider his correspondence as a complaint. It also agreed that, if the review concludes that the complaint does meet the criteria for the Welsh Government’s complaints process, to provide Mr A with a full response to his complaint. The Welsh Government agreed to complete these actions within 4weeks.

Mrs A complained that the Council charged an incorrect invoice for her husband, Mr B’s, ongoing care after he was discharged from Hospital. The Ombudsman was concerned that Mrs A considered that the Council provided her with incorrect information regarding the charges as it had identified errors in its complaints response, which the Ombudsman said caused frustration and confusion to Mrs A. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Council’s agreement that, within 4 weeks, it would provide Mrs A with a letter clearly stating the outstanding balance and explain how this balance was calculated.

Miss C complained about the care and treatment her father, Mr A, received from Cardiff and Vale University Health Board. Specifically, the investigation considered whether it was appropriate not to carry out a CT head scan on Mr A following his fall at University Hospital of Wales on 15 December 2023. It also considered whether the input and action by the Specialised Neuropsychiatric Rehabilitation Team was appropriate and timely, following the referral of Mr A to its service in February 2024. The Ombudsman found that whilst the Health Board’s policy stated that a CT head scan should have been carried out, there was no detriment or injustice caused to Mr A by the absence of a scan. The investigation also found that the input and action by the Specialised Neuropsychiatry Rehabilitation Team was both appropriate and timely. The Ombudsman did not uphold either complaint.

Miss C complained about the care and treatment her father, Mr A, received from Aneurin Bevan University Health Board. Specifically, the investigation considered whether Mr A’s discharge from Yysbyty Ystrad Fawr on 3 January 2024 was appropriate and whether referral to mental health or psychiatric services should have taken place sooner. The Ombudsman found that Mr A’s discharge from the hospital was not reasonable or appropriate and was instead premature and inadequately planned. Furthermore, the investigation found that mental health/psychiatric input should have been requested before discharge. This was an injustice to Mr A and his family. The Ombudsman upheld both complaint points. The Health Board accepted the Ombudsman’s recommendations. This included an apology and an offer of financial redress for £1000 to Miss C and to share the report with relevant clinicians who provided care and with the Health Board’s Quality and Safety Committee. The Health Board agreed to provide evidence that training on mental capacity assessment and deprivation of liberty safeguards had been implemented. It also agreed to implement training and a number of service improvements around discharge planning processes aimed at addressing the causes of the failings in this case. Finally, it agreed to carry out an audit of capacity and depravation of liberty safeguarding assessments completed within the previous year and to address any failings identified as a result.

Mr A complained that staff at Betsi Cadwaladr University Health Board (“the Health Board”) had harassed him and scheduled appointments without his consent. The Ombudsman found that although the Health Board had responded to Mr A’s complaint it had not provided a satisfactory response and had not responded to subsequent complaints. The Ombudsman decided to settle the complaint without an investigation on the basis that within 1 month of issuing the decision letter the Health Board would: Write to Mr A and provide a detailed complaint response to his initial and all subsequent complaints.

Mr A complained about Cardiff Council’s handling of his application for a vehicle crossover outside his home. The Council approved the application in writing, but days later reversed the approval, without notice, on grounds already know at the time of the site inspection. Mr A complained to the Council but did not receive a complaint response. The Ombudsman found that, although the Council had acknowledged and considered Mr A’s complaint, it was closed without him being informed or a complaint response provided. Mr A was inconvenienced by the Council’s failure to respond to his concerns, which caused him stress, anxiety 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 delay in addressing his concerns.