PSOW Individual Decisions

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 A complained that the Surgery failed to respond to the complaint she submitted to it in October 2025. The Ombudsman found that the Surgery had failed to consider the complaint via the complaint procedure and formally respond to Miss A. 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 Surgery’s agreement to, within 4 weeks, provide the formal complaint response which will also include an apology and explanation for the delay in responding.

Mr F complained that Cardiff Council improperly issued him a warning notice for “illegal dumping” of waste outside his property, and that the warning and the Council’s response to his complaint contained incorrect information regarding his waste collection day. Mr F also complained about a lack of clarity around the correct colour for waste disposal bags. The Ombudsman found that Mr F was improperly issued a warning because the Council incorrectly stated that his collection day was a day later than it is, which the Ombudsman said caused Mr F distress and frustration. The Ombudsman also found that the Council’s website did not specify the accepted colour of waste disposal bags, which she said caused Mr F confusion. The Ombudsman decided to settle the complaint without a formal investigation. The Ombudsman sought and gained the Council’s agreement to, within 2 weeks, apologise to Mr F for the distress and inconvenience caused to him by the correspondence he received and the error regarding his waste collection date, provide assurances to Mr F that the incorrect correspondence would have no ongoing impact on him (should any future potential incidents of incorrect waste placement occur), and to offer him a redress payment of £50. The Council also agreed to update the guidance on its website to clarify the accepted colour of waste disposal bags within 8 weeks.

Mrs B complained that Cardiff and Vale University Health Board failed to issue a further response to her complaint which, she made to it in June 2025. The Ombudsman found that whilst the Health Board had not provided a further response to Mrs B’s complaint at the time of her complaint to this office, it had subsequently issued a further response. She said that this caused frustration to Mrs B. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to, within 3 weeks, apologise and provide an explanation to Mrs B for the delay and lack of updates, and offer £75 redress in recognition of her time and trouble in making her complaint to the Ombudsman.

Mrs A complained about the care and treatment provided to her late husband, Mr B, in relation to a large bowel obstruction and sigmoid stricture. Following advice at an outpatient appointment in April 2024, Mr B opted for further investigations, rather than surgery. By the next appointment, his health had declined to the extent he was no longer fit for surgery. Mrs A said that, despite worsening symptoms, Mr B was not admitted to hospital for nutritional support, monitoring, or timely surgery. Mr B sadly passed away following an emergency admission and surgery in September 2024. Mrs A was dissatisfied with the Health Board’s complaint response. The Health Board was unable to provide records relating to the relevant outpatient appointment. The Ombudsman found that this raised concerns about the Health Board’s record-keeping. As a result, if the Ombudsman were to investigate Mrs A’s complaint, it would be difficult to establish with any certainty what was discussed in order to decide whether appropriate advice was given. This caused uncertainty and an injustice for Mrs A. The Ombudsman decided to settle the complaint without investigation. The Health Board agreed to, within 4 weeks, provide Mrs A with a written apology for the lack of clinical records in relation the relevant consultation and the fact that this has prevented the Ombudsman investigating the matter. It also agreed to, within 4 weeks, provide Mrs A with a further complaint response setting out the learning points identified and the action taken as a result.

Mrs X complained about the care that Cardiff and Vale University Health Board provided to her late father, particularly in relation to events after his death. She said that the Health Board had issued a response to her complaint, but she was dissatisfied with the outcome. The Ombudsman decided that the Health Board’s response to Mrs X’s complaint, did not address all of her concerns. She decided to settle the complaint without an investigation. The Ombudsman sought and obtained the Health Board’s agreement to provide Mrs X with a further response within 6 weeks.

Ms S complained that Cwm Taf Morgannwg University Health Board failed to respond to her complaint about a hospital admission which she submitted in July 2025. The Ombudsman found that the Health Board had provided Ms S with a complaint response about other issues she had raised but it had not addressed the issues she raised in July 2025. The Ombudsman sought and gained the Health Board’s agreement to, within 5 working days, apologise to Ms S and to provide confirmation that her complaint would be investigated in accordance with The National Health Service (Concerns, Complaints and Redress Arrangements) (Wales) Regulations 2011.

Mrs A complained that there were repeated failures by Welsh Ambulance Services University NHS Trust (“the Trust”) to appropriately prioritise an emergency response when her husband, Mr A, called 999 after midnight on 30 May 2025, resulting in a significant delay in his receiving appropriate medical care. Mrs A was concerned that the delay led to Mr A experiencing avoidable excruciating pain, and contributed to his premature death. The Ombudsman identified that although Mrs A’s complaint against the Trust had been considered in an investigation by the Health Board in her area, her concerns had not been adequately addressed. The Ombudsman considered that a full and thorough investigation of Mrs A’s complaints by the Trust could potentially resolve her complaint. The Trust agreed to within 1 month initiate a “Putting Things Right” complaints investigation with reference to those aspects of Mrs A’s complaint which related to care provide by the Trust.

Mrs A complained that she had not received a complaint response from Swansea Bay University Health Board (“the Health Board”), despite complaining 7 months ago. At assessment, the Ombudsman found that the Health Board had not provided a complaint response to Mrs A. The Health Board agreed, within 4 weeks, to provide a complaint response to Mrs A, including apologies and reasons for delay.

Mr A complained that Powys County Council failed to respond to the complaint regarding the length of time to hold the multi-agency meeting. The Ombudsman found that, while the Council had provided explanations regarding other concerns, it has not addressed the matter of the delays in holding the multi-agency meeting. 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, undertake a review of the Section 5 process and provide an outcome to the complainant.

Mrs A complained that there was a failure by the GP Practice to refer her brother to secondary care in a timely manner between March and May 2024. As a result, there was a delay in identifying that his previously diagnosed bowel cancer had spread to his right parotid gland (a salivary gland just beneath and in front of the ear). The investigation found that the GP Practice’s management and care was reasonable and appropriate. Based on her brother’s presenting symptoms, there was no reason to suppose that they were anything other than an ear infection/congestion. Mrs A’s complaint was not upheld.

Mrs X complained that Conwy County Borough Council failed to provide her son with appropriate educational provision. She said that this resulted in significant gaps in his education, emotional wellbeing, and social development. The Ombudsman noted that the Council had provided a response to Mrs X’s complaint, however she was concerned that it did not address all of Mrs X’s concerns. As a result, she decided to settle the complaint without an investigation. The Ombudsman sought and obtained the Council’s agreement to contact Mrs X within 3 weeks to arrange a meeting to discuss all aspects of her complaint.

Miss A complained that Betsi Cadwaladr University Health Board had failed to arrange a meeting which she requested in September 2025. The Ombudsman found that the Health Board had failed to arrange a meeting with Miss X and her advocate. The Ombudsman said this caused frustration for Miss X. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to, within 4 weeks, offer an apology and explanation to Miss X for the delay in arranging a meeting and to arrange a meeting with Miss X and her advocate.

Mr A complained that Bridgend County Borough Council failed to respond to the complaint that was referred to the Council by our office in June 2025. The Ombudsman found that the Council failed to respond to the complaint raised which the Ombudsman said 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 2 weeks, issue the complaint response which will include an apology and explanation for the delay and a £100 financial redress offer in recognition of the delays.

Mrs B complained that Aneurin Bevan University Health Board failed to issue a response to her complaint, which she made to it in May 2025. The Ombudsman found that the Health Board had failed to issue a complaint response. She said this caused frustration and uncertainty to Mrs 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 to Mrs B for the delay, offer a redress payment of £75 in recognition of her time and trouble in making her complaint to the Ombudsman, and provide a complaint response within 4 weeks.

Mrs H complained that Hywel Dda University Health Board failed to issue a response to her complaint which, she made to it in May 2025. The Ombudsman found that whilst the Health Board had not provided a response to Mrs H’s complaint at the time of her complaint to this office, it had subsequently issued a response. She said that this caused frustration to Mrs H. 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 to Mrs H for the delay, and offer £75 redress in recognition of her time and trouble in making her complaint to the Ombudsman within 3 weeks.

Mr C complained that Wrexham Council had refused to repair a damaged water pipe, leading to dampness in his property. The Ombudsman decided that the Council’s investigation of Mr C’s complaint was not sufficiently robust. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Council’s agreement for a manager to review all the evidence relating to the case and provide Mr C with a further response within 4 weeks.

Mrs C complained that Hywel Dda University Health Board had failed to arrange a face-to-face meeting regarding the treatment and care her late mother had received. The Ombudsman found that Mrs C had complained to the Health Board 7 months ago and had still not received a formal complaint response. The Ombudsman said this left many unanswered questions for Mrs C and decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to, within 4 weeks, apologise for the delay and issue a complaint response to Mrs C as a meeting has taken place already.

The investigation considered whether the dentures provided to Mr A were clinically appropriate, including the advice provided about their longevity. By way of an outcome Mr A wanted the cost of the dentures reimbursed. The Dental Practice agreed as part of a settlement to reimburse Mr A the sum of £260 for the dental treatment it provided in 2025, which included the cost of the dentures. It also said that as part of wider learning the Dental Practice will feed back any points of learning to the Dentist.

Mr A complained that his place on the waiting list for surgery was reset when he rearranged an appointment. The Ombudsman recognised the language used in the complaint response may have led to confusion. However, as Mr A gave prior notice of his inability to attend a mutually agreed appointment, this was considered a ‘Could Not Attend’ by the Health Board. As per the Revised Rules for Managing Referral to Treatment Waiting Times for Phased Implementation April 2017 (“the Rules”), the Health Board was, therefore, entitled to reset his clock on the waiting list. However, the Ombudsman was concerned that the Health Board had not communicated this to Mr A when rebooking his appointment. The Ombudsman sought and gained the Health Board’s agreement to, within 4 weeks, apologise to Mr A for not communicating that his clock had been reset when rebooking his appointment, and to ensure that all patients are informed of resets to their place on the waiting list going forward, as per the Management of Referral to Treatment Waiting Times Guidance April 2025, which now applies. The Health Board agreed to do so.

Mrs A complained about her brother, Mr B’s, care and management by the Health Board. We investigated her concerns about whether Mr B’s clinical management between January and June 2023 was appropriate. We also investigated whether the cancer diagnosis Mr B received in May 2024 could have been identified sooner. Finally, we investigated Mrs A’s concern that the Health Board’s complaint response was compromised by factual inaccuracies. The investigation found that, while Mr B was seen within an appropriate timescale following a dental referral in January 2023, the decision to remove him from the cancer pathway at his appointment in February 2023 was not appropriate. This led to a delay in carrying out a biopsy, reaching a diagnosis and commencing treatment for Mr B’s diagnosed cancer. This was a service failure. Even taking into account the delay in confirming Mr B’s oral cancer diagnosis, Mr B’s management and treatment would have been the same, even if the diagnosis had been reached sooner. This complaint was not upheld. The investigation found, in relation to the concern about whether Mr B’s cancer diagnosis in May 2024 could have been identified sooner, that the Health Board’s management of a non-specific lung nodule during a staging CT scan in May 2023 was appropriate and its management of Mr B at a maxillofacial appointment in February 2024 was appropriate, following a GP referral reporting a new lesion on the tip of Mr B’s tongue. The investigation found that while there were elements of the clinical management at a rheumatology appointment in April 2024, to investigate a cause for Mr B’s back pain, that were appropriate, there were a number of red flag indicators that, taken together should have prompted further assessment of Mr B’s symptoms. This was a service failure. Even taking this into account, an earlier identification of Mr B’s lung lesion and metastatic disease would not have altered the trajectory of Mr B’s cancer, management of if, or led to further

Ms B complained that Pobl failed to address and resolve certain matters of her complaint in its complaint response. The Ombudsman found although most matters of Ms B’s complaint had been addressed, certain issues had not been addressed. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained Pobl’s agreement to provide a full complaint response specifically addressing the matters that were missed, along with an apology and explanation for the oversight.

Mrs B complained that Cardiff and Vale University Health Board had not properly assessed her son, Mr A’s mental health needs. She said that he had been discharged from services without support and she was worried about his welfare. The Ombudsman decided that there had been errors in progressing referrals that caused a delay in offering Mr A the support he required. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to offer Mr A support, and write to him within 1 month to apologise for the delays.

We investigated Mr A’s complaint against a GP Practice in the area of Aneurin Bevan University Health Board (“the Practice”) that 2 safeguarding referrals made by the Practice to Social Services were not appropriate. The investigation found that both referrals were appropriate and the complaint was not upheld. The decision to make the first referral was appropriate. Even though there was no substantial new accusation contained in the second referral, safeguarding guidance is clear that this should not deter a professional from making a further referral if concerns continue.

Ms B complained about the care and treatment she received from Cwm Taf Morgannwg University Health Board. The investigation considered whether the care and treatment provided to Ms B on 23 December 2023 led to increased risk of her later diagnosis of post-dural puncture headache (“PDPH” – a headache caused by fluid leaking from the puncture site following a spinal procedure). It also considered whether the care and treatment provided to Ms B on 26 December was clinically appropriate in light of her presenting symptoms and clinical history. The Ombudsman found that whilst Ms B’s epidural catheter (a small, flexible tube placed in the spine to deliver pain relief medication) was accidentally cut, the insertion of a second epidural catheter was clinically appropriate given the circumstances. It found that this did increase the risk of Ms B’s later diagnosis of PDPH, however, the Health Board had acted to mitigate such risks. The investigation also found that the care and treatment provided to Ms B, on 26 December, was clinically appropriate, given that she was discharged based upon an appropriate review of her presenting symptoms. The Ombudsman did not uphold the complaints.