PSOW Individual Decisions

Ms A complained that she had not received a suitable response to her complaint which she submitted to Powys Teaching Health Board (“the Health Board”). She said that the specific questions she raised had not been addressed sufficiently or at all. The Ombudsman found that although the Health Board had provided a detailed and comprehensive response to about the care received by Ms A’s mother, it did not adequately address Ms A’s questions. The Ombudsman was also concerned that following the complaint response the Health Board told Ms A on 25 November 2025 that she would receive post-response correspondence which addressed her questions with 2 weeks. At the time the complaint was brought to the Ombudsman (2 March 2026), no such response had been received. The Ombudsman decided to settle the complaint without an investigation on the basis that within 2 weeks of issuing the decision letter the Health Board would issue Ms A a complaint response which provides a comprehensive answer to the 6 questions she raised in her original complaint.

Mrs A complained that Powys Teaching Health Board had refused to investigate her complaint without her son’s consent. Mrs A also said that the Health Board failed to respond to the concerns relating to her own experience, which did not require her sons consent. The Ombudsman found that the Health Board had overlooked providing a response to the concerns which did not require Mrs A’s sons consent. The Ombudsman said this caused uncertainty and frustration for Mrs A. She 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 for the oversight and provide a complaint response to the concerns which do not require Mrs A’s sons consent.

Ms A complained that the Practice failed to respond to aspects of the complaint she submitted in June 2025. The Ombudsman found that, while the Practice had responded, it had failed to respond to all of the concerns raised. The Ombudsman said this caused uncertainty and frustration for Ms A and decided to settle the complaint without an investigation. The Ombudsman sought and gained the Practice’s agreement to, within 2 weeks, offer an apology to Ms A for not addressing all the concerns and explain why, in addition to also providing a complaint response that responds to the concerns that were not addressed originally.

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.

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.

Mrs A complained to Powys Teaching Health Board regarding the impact a policy change had on her. The Ombudsman found that the Health Board had not directly responded to Mrs A and did not address every issue she had raised. The Ombudsman considered that this caused Mrs A frustration due to unanswered questions and decided to settle the complaint without an investigation. The Ombudsman gained the Health Board’s agreement to respond to Mrs A’s complaint, commenting on each of the issues she raised, within 4 weeks.

Ms A complained that a GP Practice in the area of Powys Teaching Health Board (“the Practice”) did not provide a response to her complaint, submitted in June 2025. She also complained about the behaviour of a staff member in July 2024 and a warning letter sent to her aunt and uncle. The Ombudsman decided that nothing further could be achieved in respect of the behaviour of a staff member and the warning letter. The Practice’s actions had been reasonable. However, it was noted that after Ms A had been invited to submit a complaint, it was then not responded to. Whilst the Ombudsman acknowledged the Practice’s position, it was decided that a letter to Ms A in response was needed. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Practice’s agreement to, within 2 weeks, provide Ms A with a letter in response to her complaint submitted on 19 June 2025.

Ms A complained that Powys Teaching Health Board assessed and then discharged her son from the neurodevelopment pathway. She also said that the Health Board did not respond to all of the concerns raised in her initial complaint. Whilst the Ombudsman noted that Ms A’s son had initially been discharged from the neurodevelopment pathway further information received confirmed that Ms A’s son was in the process of being assessed again. It was therefore decided that this matter should not be investigated. However, the Ombudsman noted that the Health Board had not provided a full response to Ms A’s submitted complaint. 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 A and provide an updated complaint response addressing the concerns that had not previously been responded to in her complaint submitted in June 2025.

Miss A complained that the GP Practice had removed her from its practice list. She also complained about the information provided to her by the Health Board in response to her complaint. The Ombudsman found that the GP Practice had not provided Miss A with warnings prior to, or an explanation about, her removal from the practice list in line with its policy. In addition, the Health Board provided Miss A and the local Senedd Member with a response to her complaint that contained inaccurate information about her removal from the practice list. The Ombudsman obtained the GP Practice’s agreement to, within 4 weeks, review the action taken and consider whether it has appropriate procedures and guidance in place for considering removing patients from its list. It also agreed to provide Miss A with a specific explanation about why the GP Practice considered it appropriate to remove her from its patient list without warning or explanation. The Health Board agreed to provide Miss A and her local Senedd Member with an apology for the inaccurate information previously provided and an explanation of why this occurred, within 4 weeks.

Miss A complained that the GP Practice had removed her from its practice list. She also complained about the information provided to her by the Health Board in response to her complaint. The Ombudsman found that the GP Practice had not provided Miss A with warnings prior to, or an explanation about, her removal from the practice list in line with its policy. In addition, the Health Board provided Miss A and the local Senedd Member with a response to her complaint that contained inaccurate information about her removal from the practice list. The Ombudsman obtained the GP Practice’s agreement to, within 4 weeks, review the action taken and consider whether it has appropriate procedures and guidance in place for considering removing patients from its list. It also agreed to provide Miss A with a specific explanation about why the GP Practice considered it appropriate to remove her from its patient list without warning or explanation. The Health Board agreed to provide Miss A and her local Senedd Member with an apology for the inaccurate information previously provided and an explanation of why this occurred, within 4 weeks.

Mr A had complained about issues relating to the care provided to him by the GP Practice. The Ombudsman found that while the GP Practice had provided Mr A with a complaint response, it had failed to fully respond to the concerns he had raised. That amounted to maladministration which caused him an injustice. The Ombudsman obtained the GP Practice’s agreement to investigate and respond fully to Mr A’s concerns and to apologise to him for not doing so in the first place. The GP Practice agreed to undertake these steps within 2 months.

Mr A complained that the dental practice did not fully respond to his formal complaint submitted to it in October 2024. The Ombudsman decided that the dental practice had failed to respond to a second letter of complaint from Mr A. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the agreement of the dental practice to respond to Mr A’s second letter of complaint and apologise for the delay in responding fully. The dental practice agreed to do this within one month of the Ombudsman’s decision.

Miss D complained about care and treatment provided to her by Wye Valley NHS Trust (“the Trust”) on behalf of Powys Teaching Health Board (“the Health Board”). We investigated whether Miss D received appropriate care following her emergency surgery at Hereford Hospital (“the First Hospital” – operated by the Trust) in May 2022, taking into account her underlying neurological condition and specialist input. The investigation found that there were no missed opportunities to refer Miss D to a neurologist sooner following her emergency surgery. It also found that she received appropriate care after she was transferred to Bromyard Community Hospital (“the Second Hospital” – operated by the Trust), and that appropriate investigations were carried out under the guidance of a neurologist. The investigation found that there was a failure to provide Miss D with physiotherapy during her admission to the First Hospital, despite this having been requested following the surgery. This was a missed opportunity to provide exercises that may have reduced the pain and discomfort she experienced during her transfer to the Second Hospital. The complaint was upheld to this limited extent. The Ombudsman made recommendations to the Health Board as it was ultimately responsible for the care provided. The Health Board agreed to apologise to Miss D and pay her £500 to reflect the injustice caused by the Trust’s failure to provide physiotherapy care at the First Hospital. It also agreed to request as part of its commissioning arrangements, that the Trust arrange for the report to be discussed at a relevant clinical governance meeting and to remind relevant clinicians of the importance of carrying out and documenting neurological examinations where a neurological concern arises, and documenting appropriate discussions with patients when they raise concerns about their care.

Mr A complained that a GP Practice in the Powys Teaching Health Board area (“the Practice”) failed to provide appropriate care and treatment in relation to his presenting symptoms. Mr A was later diagnosed with polymyalgia rheumatica. Mr A was particularly concerned that it was unreasonable for the Practice to discontinue steroid use after asking them to be continued and reporting pain in their absence, that the Practice had not conducted the correct blood tests, and that the Practice could have taken steps to diagnose Mr A sooner. The investigation found that the care provided had been of an appropriate standard and that there was no evidence that the Practice could have taken steps to diagnose Mr A sooner without the benefit of hindsight. The complaint was therefore not upheld.

Ms A complained about the provision of hormone medication to her daughter, Ms B, via the GP and the Local Gender Team within the Health Board’s area. The Ombudsman found that the Health Board did not currently have a consistent pathway for gender patients to be prescribed specialist hormone medication with appropriate monitoring and review. The Health Board was aware of the issues regarding this service. The Health Board agreed that, within six months, arrangements for the prescribing, monitoring and review of hormone treatment (for all gender service patients within the Health Board’s area) would be transferred to the Health Board’s Local Gender Team and provided via local sexual health clinics. In the interim, it would continue to provide Ms B with the required medication via her local sexual health clinic.

Ms A complained to the Ombudsman about the care and treatment her late father received from Powys Teaching Health Board (“the Health Board”). The Ombudsman found that the Health Board’s decision upon which community hospital to move her father to was reasonable and taken based on availability and suitability at the time. However, the Ombudsman found that the Health Board had failed to respond to Ms A’s concern that the family were not made aware of her father’s pancreatic cancer and dementia diagnoses’. The Ombudsman sought and gained the Health Board’s agreement to apologise to Ms A and to provide a response to her concern, within 3 weeks.

Ms A complained that Powys Teaching Health Board (“the Health Board”) failed to address her concerns about its role as commissioner of health services provided to her by her GP Practice (“the Practice”) and an NHS Trust in England (“the Trust”). Specifically, she complained that following poor communication between the Practice and the Trust regarding her need for sedatives prior to an imaging scan, the first scan had to be cancelled at short notice. She said that as a result of the approach adopted by the Practice and the Trust, she was forced to make a 50-mile round trip to collect sedatives before the re-arranged scan. The Ombudsman was concerned that the Health Board’s complaint response had not addressed key questions raised by Ms A, including whether it was satisfied that the policies of the Practice and the Trust regarding prescribing sedatives for patients in Ms A’s situation were reasonable. In the interests of settling the complaint, the Health Board agreed to carry out a number of actions, within 8 weeks, including to issue a further complaint response to Ms A, apologise to her for the failure to fully respond to the complaint previously, and offer her a payment of £350 in respect of time and trouble.

Mrs C complained about the care and treatment her late mother, Mrs B, received from a care home (“the Care Home”), in the area of Powys Teaching Health Board. The investigation considered whether the nursing care and treatment received by Mrs B at the Care Home was of an appropriate standard in the 2 weeks before she sadly died on 21 March 2023.  Mrs C said that concerns about Mrs B’s dehydration were not appropriately managed and that the Care Home did not contact the GP soon enough for a more timely re-assessment of her diuretic medication (that increases the amount of urine produced). The Ombudsman found that the nursing care and treatment received by Mrs B at the Care Home from 7 to 21 March 2023 was of an acceptable standard and that concerns were appropriately discussed with the GP.  The Ombudsman did not uphold this complaint.

Ms A complained that she put in a claim for retrospective Continuing NHS Healthcare funding (“CHC”) in December 2019 and to date had not received a decision. Ms A said that she chased the Health Board for 4 years and considers this to be unacceptable. The Health Board has agreed to apologise for the delay in providing Ms A with a decision and to provide a CHC decision letter within 6 weeks . The Ombudsman considers this to be reasonable and the complaint was settled.

Ms A complained about the care and treatment that her late father, Mr B, received from the Practice, including that it did not adequately treat her father’s anaemia. The Ombudsman decided that although the Practice prescribed one month’s folic acid, no further investigation of Mr B’s folate level were carried out after the month’s prescription ended. On balance, it was likely that the folic acid prescription should have continued. She decided to settle the complaint without an investigation. She sought and gained the Practice’s agreement, that within 20 working days it would write to Ms A to acknowledge and apologise that the management of her father’s folate deficiency was not appropriate, and to review its treatment of this condition to improve care for future patients.

Ms X complained about the standard of care provided to her father, Mr Y, when he was an inpatient at Bronllys Hospital, which is a GP-led hospital service. Specifically, Ms X complained that doctors should have diagnosed Mr Y’s heart failure sooner and arranged an earlier transfer to a different hospital (for acute care). The Ombudsman found that the care provided to Mr Y was appropriate. Mr Y was appropriately monitored in hospital and his test results did not specifically point to heart failure. The decision to transfer him to a different hospital was also reasonable and timely, as he had become unwell, and his condition did not improve. There was nothing to suggest that additional action or treatment would have affected the outcome for Mr Y, given his deteriorating heart function. The Ombudsman did not uphold the complaint.

Mr A complained that Powys Teaching Health Board had not correctly dealt with his claim for Continuing Health Care payments for his late mother. The Ombudsman decided that when investigating Mr A’s complaint, the Health Board had not appointed a suitably independent investigator to consider and respond to his complaint. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to write to Mr A within 20 working days to acknowledge and apologise for the error in how it dealt with his complaint and identify learning to ensure suitability independent investigators are appointed to investigate complaints.

Ms C complained about care and treatment provided to her late brother, Mr A, by a GP Practice (“the Practice”) in the area of Powys Teaching Health Board. The investigation considered whether the Practice missed opportunities to carry out earlier investigations or referrals that would have allowed Mr A’s haemochromatosis (an inherited condition where iron levels in the body slowly build up over many years which untreated can damage parts of the body such as the liver, joints, pancreas, and heart) to be diagnosed and treated sooner. The investigation found no evidence that there were any missed opportunities by the Practice to detect Mr A’s haemochromatosis at an earlier stage. The Ombudsman did not uphold the complaint.

Mr A complained that he was unhappy with Powys Teaching Health Board’s (“the Health Board”) review into his son’s care. Mr A also said that the Health Board had misdiagnosed his son, dating back to 2009. The Ombudsman found that the misdiagnosis from 2009 was out of time for consideration. However, she also found the Health Board’s review of his son’s care had an error in respect of the date of an incident. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to, within 20 working days, apologise to Mr A for the error committed in the review of his son’s care and to offer her a redress of £250 in recognition of the time and trouble in Mr A pursuing his complaint through the Ombudsman on two separate occasions.

The Ombudsman considered complaints made by Ms A about her treatment by the Health Board, specifically that the Community Mental Health Team (“CMHT”) Team Lead who spoke to her on 29 January 2021 did not support her sufficiently and breached her duty of care to Ms A, and that the record of the call made by the CMHT Team Lead was inaccurate. Ms A also complained that her later discharge from the CMHT, including her transfer of care to a new locality, was not managed appropriately, and that the Health Board’s response to her complaint was insufficient and not in line with the Putting Things Right (“PTR”) process. Based on the evidence provided, which included a covert recording made by Ms A of the January telephone conversation, the Ombudsman found that it was more likely than not that several key elements of the Health Board’s summary of the call within the clinical records were inaccurate. As a result, she found that, whilst the support provided by the CMHT during the call was not inappropriate, given that Ms A indicated a possible suicidal intention, references to support agencies should have been made, and, as they were not, this was an injustice to Ms A. She found that although the complaint response was largely in line with PTR, it did not appear to have sufficiently considered Ms A’s recording of a telephone call when creating the response, or when subsequently providing comments to the Ombudsman. These 3 complaints were therefore upheld. The Ombudsman found that Ms A’s discharge and transfer were generally managed appropriately so this complaint was not upheld. The Ombudsman recommended that the Health Board should apologise to Ms A for the issues identified and offer her a payment of £750 in recognition of the failure to refer to support agencies within the telephone conversation and poor complaint handling. She also recommended that the Health Board should remind all staff within the CMHT of the importance of completing records as soon as possible after the