PSOW Individual Decisions

Complaint that the HB failed to address her concerns about a failure to arrange a Multidisciplinary Team (MDT) review. Complainant thought her case was being referred for MDT review in August 2024.

Ms B complained that Cwm Taf Morgannwg University Health Board had failed to provide a formal response to her formal complaint, which she made to it in April 2025. The Ombudsman found that whilst the Health Board had provided an informal response to Ms B, despite Ms B making it clear she had made a formal complaint, it had failed to provide a response in accordance with the ‘Putting Things Right’ procedure. She said that this caused uncertainty and frustration to Ms B. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to write to Ms B with an apology for the delay in issuing a formal complaint response, provide a further apology for the lack of regular and meaningful updates, offer to pay £75 in redress and issue a formal complaint response within 6 weeks.

Mr B complained that the Health Board failed to respond to his complaint about the length of time he has been waiting to have an operation and why he has been removed from the priority list. The Ombudsman found that whilst the Health Board had been in touch with Mr B, it had failed to log his concerns under the Putting Things Right (“PTR”) concerns procedure. She said that this caused frustration and uncertainty to Mr B. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to write to Mr B with an apology for the oversight and issue PTR complaint response within 6 weeks.

Mrs A complained that if her son, Mr B, had been appropriately scanned, assessed and investigated following his hospital admissions in July and August 2023, his brain tumour could have been detected earlier, allowing treatment to start sooner. The investigation specifically focused on whether Mr B’s clinical management between July and September 2023 was of an acceptable standard. The Ombudsman found that Mr B’s clinical management between July and September 2023 was of an acceptable standard and the complaint was not upheld. In relation to his ED attendance and admission in July, the Ombudsman found that the investigations carried out during Mr B’s ED attendance were appropriate based on his presentation and in line with national guidance. During his July admission, Mr B’s management was again in line with national guidance and of an acceptable clinical standard, as was the decision to request an outpatient MRI scan and neurology review. The Health Board had already accepted a shortcoming in that the outpatient MRI referral was not done. However, despite this, Mr B underwent a further MRI scan 4 weeks after he was discharged which was within the recommended timescales. In considering Mr B’s ED attendance in August and subsequent admission, while there was a short delay in ED triage, the Ombudsman found that this would not have altered Mr B’s management. In terms of his hospital admission, Mr B underwent a number of investigations and scans, and his management followed the key recommendations outlined in national stroke guidelines. Furthermore, when a CT scan in August reported an intracranial hemorrhage with unclear cause, further scans were carried out to determine the cause of Mr B’s hemorrhage, which was clinically appropriate, as was the plan to arrange a follow-up scan in 3 months.

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.

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.

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.

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.

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 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.

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.

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.

Mrs A complained about the care and treatment she received during an appointment with a General Practitioner. The Ombudsman found that the Surgery responded to her complaint but failed to directly address the concerns she raised. This caused additional frustration and uncertainty for Mrs A. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Surgery’s agreement to issue a further complaint response to Mrs A, within 3 weeks, addressing the concerns raised.

Mr B complained that his father, Mr A, was discharged prematurely by Cwm Taf Morgannwg University Health Board (“the Health Board”) from a hospital on 20 August 2024, without a care plan or appropriate assessment of risk. The investigation found that Mr A’s discharge from the hospital was appropriate and so the complaint was not upheld. However, the Health Board was invited to provide out-of-hours contact details to patients who have been fitted with a stent and discharged on the same day.

We investigated a complaint brought by Mr A on behalf of his father Mr H which focused on whether it was appropriate to discontinue treatment and monitoring of Mr H on 8 December 2023, and once it was agreed to re-start treatment, whether there was a delay in this being commenced. The investigation also considered whether Mr H received appropriate care and treatment in respect of skin integrity before being admitted to a ward on 11 December. The Ombudsman did not uphold Mr A’s complaint. The investigation found that although there were some issues in how decisions were communicated with Mr H’s family the decision to discontinue treatment and monitoring of Mr H was appropriate. It was also found that as Mr H made a recovery and was well enough to be discharged from the hospital, that any delay in re-starting treatment did not have a negative impact on Mr H. The investigation also found that the care received by Mr H in regard to his skin integrity was of an appropriate standard. However, the Health Board was invited to consider points of learning around General Medical Council (“GMC”) guidance on communicating with a patient’s family members when making decisions for a patient who lacks capacity. The Health Board was also invited to advise staff to record the actual time of administration of medication.

Mrs X complained that Cwm Taf Morgannwg University Health Board failed to communicate with her in relation to a face to face meeting. The Ombudsman found that the Health Board had arranged a meeting with Mrs X. However, the Health Board had delayed confirming a meeting room with Mrs X’s advocate. The Ombudsman said this caused uncertainty and frustration for Mrs X. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to, within 1 month, apologise to Ms X for the delay in arranging a meeting and to arrange a meeting with Mrs X and her advocate.

Mrs A complained because she was unhappy with Cwm Taf Morgannwg University Health Board’s care and treatment of her father between August and October 2024. The Ombudsman decided that nothing further could be achieved in respect of the care provided. The Health Board’s complaint response appeared to be reasonable. It had apologised where appropriate to do so, and outlined the actions it had taken in response to acknowledged failings. However, the Ombudsman noted that within its response the Health Board had offered a meeting to discuss a safeguarding concern that Mrs A had raised. The Ombudsman was concerned that the meeting had still not taken place. 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 Mrs A for its failure to arrange a meeting and to finalise meeting arrangements to discuss the safeguarding concern and the overall complaint response.

Mrs L complained that Cwm Taf Morgannwg University Health Board had failed to provide her with the medical records it relied on when investigating her complaint, which Mrs L is entitled to under the ‘Putting Things Right’ complaints process. The Ombudsman found that, following receipt of the Health Board’s complaint response, Mrs L had requested a copy of the medical records which the Health Board had relied on when investigating her complaint. There had been a significant delay in the Health Board providing Mrs L with the relevant records, which the Ombudsman said caused Mrs L frustration and uncertainty. The Ombudsman decided to settle the complaint without a formal investigation. The Ombudsman sought and gained the Health Board’s agreement to apologise to Mrs L for the delay and explain the reasons for it, and to provide the relevant records to Mrs L within 4 weeks.

Miss S complained that Cwm Taf Morgannwg University Health Board failed to respond to her emails concerning the conduct of a medical professional. The Ombudsman found there had been a delay with the Health Board addressing the issues she raised due to the closure of a hospital putting extreme pressures on its staff. This caused additional frustration and uncertainty for Miss S. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to, within 4 weeks, write to Miss S to apologise for the delay and address the concerns she raised.

Mrs B complained about the care and treatment provided to her late mother, Mrs C. Specifically whether opportunities were missed to prescribe Mrs C insulin prior to her discharge from hospital and whether Ms C’s discharge from hospital was clinically appropriate and communicated appropriately. The Ombudsman found that Mrs C should have been referred for further consideration of treatment for diabetes before she was discharged from hospital. Whilst Mrs C’s discharge from hospital was clinically appropriate, aftercare and follow-up in respect of diabetes and how this was communicated was not. These failures have left Mrs B with lasting uncertainty about what the outcome may have been had they not occurred, which is an injustice to her. Whilst not an issue identified for investigation, the Ombudsman also had concerns about the complaint response Mrs B received, as it was not recorded that the Health Board considered its obligations under the Duty of Candor. This is an injustice to Mrs B who did not receive information she was entitled to. The Ombudsman sought and gained the Health Board’s agreement to apologise to Mrs B for the failings identified during this investigation and to ensure that clinicians involved in Mrs C’s care were familiar with the diabetes referral process and to remind them of the importance of keeping accurate and sufficiently detailed records. It also agreed to provide refresher training to staff involved in investigating Mrs B’s complaint on the Duty of Candour and to reflect on why the consideration that the Duty of Candour may be engaged was not recorded. The Health Board also agreed to review the role of the Diabetes Team in supporting hospital discharge and to share the investigation report internally for wider reflection and learning.

Ms A complained about the Health Board’s delay in hip surgery for her father, Mr B. Mr B was told that his care had been transferred to a neighbouring health board. However, enquiries revealed he was not on the surgery waiting list at either health board. The investigation considered whether Mr B’s hip surgery had been delayed due to administrative, rather than clinical, reasons. The Ombudsman found that, without his knowledge, Mr B had been removed from the orthopaedic surgery waiting list. The reason for this is not clear from the Health Board’s records. The Ombudsman was concerned that Mr B had not been notified about his removal from the list (as required by national guidance), and that the Health Board had failed to rectify the situation for well over a year despite complaints being made to it. The Ombudsman was satisfied that this constituted maladministration which had resulted in a considerably longer wait for surgery for Mr B. The Ombudsman upheld the complaint. The Ombudsman made a number of recommendations which the Health Board accepted. Within 1 month: a) Arrange for the Chief Executive to make a written apology to Ms A and Mr B for the administrative error which delayed Mr B’s surgery, and for the poor and delayed response to their complaint. b) Provide a redress payment of £750 to reflect the poor response to the complaint, and the additional stress for Mr B of having to chase up the issue with the Health Board. c) Provide a redress payment of £1,500 to reflect the additional pain and suffering experienced by Mr B during the 18 months he was not on the waiting list due to administrative error. Within 4 months: d) Provide evidence to my office that it has audited its surgery waiting lists and the transferred patient lists to satisfy itself that there are no other surgery patients who have been similarly overlooked or wrongly removed from its lists. e) Share this report with its Board which should nominate a Committee to maintain oversight and monitorin

Miss C complained on behalf of her partner, Mr A, about the clinical care and treatment he received from Cwm Taf Morgannwg University Health Board (“the Health Board”) between 7 and 8 August 2023 when Mr A attended Prince Charles Hospital’s (“the Hospital”) emergency department (“the ED”). Specifically, the investigation considered whether appropriate investigations were carried out to determine if Mr A had suffered a transient ischaemic attack (“TIA”) and whether appropriate treatment was provided to Mr A during his admission and upon discharge. The investigation found that there was a lack of appropriate investigation and treatment provided to Mr A during his admission to determine whether he had suffered a TIA. The investigation also found shortcomings in record keeping and communication. Administratively, the shortcomings in record keeping amounted to maladministration and this along with the clinical care shortcomings caused an injustice to Mr A and the family, as they would never know whether further investigations at the time would have prevented a future stroke. The Ombudsman upheld Miss C’s complaint. One of the recommendations the Ombudsman made included for the Health Board to apologise to Ms C and Mr A. The Health Board was asked to remind staff about the protocol for assessment of patients presenting with symptoms as in Mr A’s case. Whilst complaint handling was not one of the heads of complaint the Ombudsman investigated, the Ombudsman was concerned about the inaccuracies in the Health Board’s complaint response and the effect it had on the integrity of the complaints process. The Ombudsman invited the Health Board to reflect and learn from its complaint handling in this case.

The investigation considered Mrs A’s complaint regarding the management and treatment she received for glaucoma (a common eye condition, usually caused by the build-up of pressure in the eye, that damages the optic nerve and can lead to vision loss). Two specific matters were investigated. Firstly, whether the treatment and management provided by the Ophthalmology Department (based within Royal Glamorgan Hospital) for glaucoma between September 2023 and April 2024 was clinically appropriate. Secondly, whether it would have been appropriate for Selective Lazer Trabeculoplasty (“SLT” – a laser treatment for glaucoma that aims to lower intraocular pressure (“IOP” – the pressure exerted by fluid in the eye) by improving fluid drainage) to have been offered to Mrs A during this timeframe. The investigation found that the management and treatment of Mrs A’s glaucoma was clinically appropriate. It was appropriate for Mrs A to continue with prescribed eye drop treatment and have a scheduled review in 6 months. Mrs A said that she was not informed that her IOP had increased; however, the investigation did not find that this constituted a service failure. Whilst there was a 1-month delay in the scheduled follow-up, this was not detrimental to Mrs A’s management. There was no evidence that Mrs A’s glaucoma had become unstable or deteriorated at the April 2024 appointment and the treatment plan was appropriate. The investigation identified concerns around miscommunication and misinformation at the April 2024 appointment regarding management and prognosis which led to Mrs A suffering stress and anxiety. The Health Board had already apologised for this, but the Ombudsman invited the Health Board to take additional action. The clinical records stated that Mrs A was offered SLT in April 2024 but declined the treatment; this was denied by Mrs A. The investigation cannot reconcile the differing versions of events with any certainty. However, the treatment prescribed to Mrs A was appr

Mrs X complained that Cwm Taf Morgannwg University Health Board failed to respond to the complaint she submitted in May 2025. The Ombudsman found that the Health Board had not provided a final complaint response and therefore the Ombudsman said this caused uncertainty and frustration for Mrs 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, issue the complaint response which will include an apology and explanation as to why the complaint was not responded to initially, and offer a £100 financial redress payment in recognition of the delays and for the time and trouble.

Mr P complained about the length of time it took Cwm Taf Morgannwg University Health Board to respond to further issues he raised after he attended a meeting with it. He said that he did not receive a response from the Health Board by the deadline set and he had to chase progress. The Ombudsman decided that there was a delay in the further response being sent and Mr P had not been updated or received an apology. She decided to settle the complaint without an investigation. The Ombudsman contacted the Health Board and gained its agreement that within 1 month it would send a written apology to Mr P for the delay in issuing the final response and for not informing him of the delay.