PSOW Individual Decisions

The Ombudsman investigated Mr A’s complaint about whether the Health Board appropriately managed his position on the waiting list for gallbladder removal surgery. The investigation found that, despite a decision being made to place Mr A on the waiting list for a laparoscopic cholecystectomy (a surgical procedure to remove the bladder) in February 2023, due to an error, this did not happen. This error was only identified in March 2024, when Mr A contacted the Health Board for an update on his treatment pathway. The investigation identified that this failure amounted to maladministration. That said, when considering what injustice this caused, the investigation found that it was unlikely that Mr A would have received an appointment for surgery and/or undergone the surgery before the error was corrected given the subsequent delay for surgery. The investigation also found that, when the error was identified, the Health Board corrected this promptly and placed Mr A on the waiting list at the position he would have been had the error not occurred. The Health Board took appropriate corrective action in addressing the error and therefore did not act with maladministration. The investigation found that communication with Mr A about his position on the waiting list amounted to maladministration. This is because the explanations provided appeared confusing and lacked sufficient clarity about why his position had changed on the waiting list, but his prioritisation had not. This was an injustice to Mr A. The complaint was upheld to this limited extent in relation to communication. The Health Board agreed to provide Mr A with an apology for the failures outlined.

Mrs A complained that she has been waiting for surgery since 2023 and the Health Board is not helping her and delaying her surgery. The Ombudsman found that the Health Board’s complaint response lacked detail and explanation as it was not compliant with the NHS “Putting Things Right” procedure. The Ombudsman said this left Mrs A with unanswered questions about her surgery and decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to within 6 weeks issue a formal complaint response, addressing the issues Mrs A raised.

Mrs A complained about the dental treatment provided to her son by Cardiff and Vale University Health Board. The Ombudsman found that the Health Board had advised Mrs A to complain to her office before issuing a complaint response in accordance with the ‘Putting Things Right’ procedure. The Ombudsman said this caused uncertainty to Mrs A about the complaints process and decided to settle the complaint without a formal investigation. The Ombudsman sought and gained the Health Board’s agreement to apologise to Mrs A for failing to provide a complaint response before signposting her to the Ombudsman’s office and to issue a full and final complaint response within 6 weeks.

Mr A complained that Cardiff and Vale University Health Board failed to fully address and respond to his complaint, which he submitted in August 2025, regarding cardiac services. The Ombudsman found that the Health Board had failed to issue a complaint response. She said this caused frustration and uncertainty to Mr A 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 Mr A for the delay and issue the full complaint response within 4 weeks.

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 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 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 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 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.

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 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.

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.

Ms C complained that there had been avoidable delays before Cardiff and Vale University Health Board offered surgery for a bladder prolapse. The Ombudsman decided that the clinical decisions were consistent with national guidelines. However, there had been errors in booking appointments and Ms C had not been consulted when her care was transferred to a different doctor. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to write to Ms C within 4 weeks to apologise for not consulting her before making decisions about her care and treatment, and to provide an update on its review of the appointment booking process. The Health Board also agreed to ensure that the service were aware of, and followed, guidance on ending professional relationships.

Mr A complained about the care and treatment provided by the Health Board. Mr A’s family complained to the Health Board on his behalf on 6 May 2024 and raised additional concerns3 weeks later. Mr A was dissatisfied with the complaint response received as this only dealt with the initial concerns raised. When Mr A queried this and raised further concerns the Health Board declined to investigate on the basis that his complaint was out of time. As a result, matters remain unresolved for him. The Ombudsman found that the Health Board had failed to respond to the further questions. In response to the email a Doctor had visited him on the ward and explained his treatment plan. However, given the level of concern and the nature of the questions raised, this was not appropriate or sufficient. This caused frustration and uncertainty for Mr A. The Ombudsman decided to settle the complaint without a formal investigation. The Ombudsman sought and gained the Health Board’s agreement to, within 6 weeks, reconsider Mr A’s complain and provide him with a further complaint response, together with a written apology for failing to address all his concerns previously.

Mr S complained on behalf of his daughter that the Health Board incorrectly discharged his daughter from its Child and Adolescent Mental Health Service and he also complained about the Health Board’s communication failures in regard to this complaint. The Ombudsman found that the Health Board failed to provide a formal, written response to Mr S’s complaint. This caused frustration and uncertainty for Mr S. The Ombudsman decided to settle the complaint without an investigation.The Ombudsman sought and gained the Health Boards agreement to, within six weeks, provide the response along with an apology and explanation for its delay.

Mr A said that, in December 2024, an application was made on behalf of his mother to initiate an NHS continuing healthcare assessment which, according to the guidelines, should have taken place within 8weeks. He said that this had not taken place or even been acknowledged. Mr A said that his mother had lost her home; she had been informed that her house would have to be sold and she had to use her own money to purchase items that she was entitled to (e.g. a wheelchair). Mr A had complained to the Health Board about this matter in March 2025 and again in August 2025 but had received no acknowledgement or response to his concerns. The Ombudsman was concerned that Mr A had not received a response to his complaint. Instead of investigating the complaint, the Ombudsman obtained the Health Board’s agreement to apologise to Mr A for failing to respond to his complaint and to provide him with a formal complaint response. It agreed to do this within 30 working days.

Mr X complained about the dental treatment provided to him by Cardiff and Vale University Health Board (“the Health Board”), specifically regarding the length of time taken to complete his treatment. This included the extraction of his wisdom teeth, the repair of chipped front teeth, and a general health check-up. The Ombudsman found that although the Health Board had addressed Mr X’s concerns informally, it had not provided a formal written response to the concerns he raised in his email of 31 January 2025. The Ombudsman therefore decided to settle the complaint without conducting an investigation. The Health Board agreed to provide a written response to Mr X’s correspondence within 1 month.

Cwynodd Ms C am safon y gofal a ddarparwyd iddi gan y Bwrdd Iechyd yn dilyn diagnosis o’i niwroma acwstig (math o diwmor ar yr ymennydd) yn 2024. O ganlyniad, gofynnodd am drosglwyddo ei gofal i ysbyty gwahanol. Ystyriodd ymchwiliad yr Ombwdsmon a oedd y gofal a’r driniaeth a ddarparwyd i Ms C yn dilyn ei diagnosis yn briodol ac yn amserol. Cydnabu’r Ombwdsmon fod y diagnosis o diwmor ar yr ymennydd, a’r driniaeth lawfeddygol a oedd ei hangen o ganlyniad, yn sefyllfa anodd a gofidus i Ms C. Fodd bynnag, nid oedd tystiolaeth bod hyn yn deillio o fethiant gwasanaeth gan y Bwrdd Iechyd gan fod yr Ombwdsmon wedi dod i’r casgliad bod y gofal a ddarparwyd yn briodol ac yn amserol, ac yn unol ag arfer clinigol derbyniol. Ni chadarnhawyd y gŵyn.

Ms A complained about the care and treatment she received between November 2022 and January 2023, following her ingestion of foreign bodies. The assessment found that the response had been delayed and it did not appear to have been responded to under the concerns process. The Ombudsman therefore sought and gained the Health Board’s agreement to respond to the complaint under the concerns process, apologise and offer a payment of £250 in recognition of the delayed response. The Health Board agreed to take this action within 2 months.

Ms A complained that the Health Board failed to adhere to the Urgent Suspected Cancer pathway and denied that she was on this pathway. At assessment, it was found that the Health Board failed to apologise to Miss A for misinforming her of the nature of her referral to Gynaecology. The Health Board agreed, within 1 week of the decision letter, to apologise to Ms A for misinforming her of the nature of her referral to Gynaecology.

Dr X complained that Cardiff and Vale University Health Board failed to respond to her complain in relation to its failure to ensure the proper security and accuracy of her records. The Ombudsman found that the Health Board had failed to correct the issue identified by Dr X when it was first raised and it had failed to issue a complaint response. The Ombudsman said this caused frustration and uncertainty for Dr X. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Boards agreement to, within 6 weeks, issue a complaint response that will include an apology for not correcting the issue when it was first raised in February 2025.

Mr X complained that Cardiff and Vale University Health Board failed to address his concerns regarding the care and treatment his late father received while in hospital. The Ombudsman found that, while the Health Board had responded to the complaint, it was not compliant with the ‘Putting Things Right’ Regulations (“PTR”) and neither did it properly address the concerns raised. The Ombudsman said this caused uncertainty and frustration for Mr 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 for not considering the complaint via the PTR process and provide a final PTR-compliant complaint response.

Mr X complained that Cardiff and Vale University Health Board failed to respond to the complaint he submitted with regards to the treatment to his legs. The Ombudsman found that, while the Health Board had considered the complaint as an early resolution, the complaint had not been considered and responded to via the Putting Things Right (PTR) procedure. The Ombudsman said this caused uncertainty and frustration for Mr 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, provide the complaint response which will also include an apology and explanation as to why the complaint was not considered under the PTR process

Mrs A complained about care and treatment provided to her husband, Mr A, by Cardiff and Vale University Health Board (“the First Health Board”) on behalf of Aneurin Bevan University Health Board (“the Second Health Board”) after he was diagnosed with a brain tumour in 2023. The investigation specifically considered whether Mr A received adequate post-operative care following neurosurgery at University Hospital Wales (“the First Hospital”), including appropriate monitoring and clinical reviews. The investigation found that Mr A received appropriate post-operative medical care. The nursing care was broadly adequate, but there was a failure to document that his identified needs relating to confusion, agitation and behaviour had been met. This complaint was upheld to that limited extent in relation to the care provided by the First Health Board . The investigation also considered whether clinicians at the First Hospital took adequate steps to ensure that Mr A’s care was patient led, taking into account his mental capacity to participate in decision-making and involving family members where appropriate. The investigation found that nursing staff failed to demonstrate that they had appropriately considered Mr A’s mental capacity to consent to nursing interventions. There were several missed opportunities to carry out an adequate mental capacity assessment and to engage with Mr A’s family to ensure that his voice was heard and that he received appropriate patient led care. There was also a failure to communicate adequately with Mrs A after she was prevented by illness from visiting the ward. This complaint was also upheld in relation to the care provided by the First Health Board. The First Health Board agreed to apologise to Mrs A and pay her £750 in recognition of the impact the failings had on Mr A and his family. It also agreed to reinforce learning points relating to nursing documentation with relevant nursing staff and to carry out an audit. This would look at compli

Mrs A complained about a safeguarding referral made by her son’s Health Visitor. Mrs A said that the referral was without justification as the Health Visitor had failed to check her son’s records and should have referred them to the GP in the first instance. Mrs A was dissatisfied with the Health Board’s complaint response, which contained conflicting information and did not address her concerns. The Ombudsman found that Mrs A had not received an adequate response to the concerns raised. Although the Health Board’s complaint response adequately addressed the initial concerns raised, Mrs A had also submitted additional questions by email. The Health Board had not considered those questions as part of its investigation. Mrs A had been inconvenienced by the organisation’s actions, which had caused frustration for her. The Health Board agreed to, within 6 weeks, consider the questions submitted to the Health Board, together with the additional matters raised in Mrs A’s complaint to the Ombudsman, and provide her with a further written complaint response. It also agreed to provide Mrs A with a written apology for the failure to consider the additional questions at the time of the initial investigation.