Mr D (anonymised) complained to Cwm Taf University Health Board about the care and treatment of his mother following her death at the Royal Glamorgan Hospital in 2012.

Despite accepting there had been a breach in their duty of care and promising to investigate the matter further Mr D heard nothing substantive from the Health Board for nearly two
years, when they claimed the original complaint record had been misplaced in a ‘culling exercise’.

In September 2015, when the Health Board had still failed to respond, the Ombudsman contacted the Chief Executive who agreed to provide Mr D with redress for the delay and to
pursue his complaint as a matter of urgency. A year later, with Mr D having heard nothing further, the Ombudsman began an investigation.

As well as the severe delay in responding to Mr D’s concerns, the Ombudsman found that the Health Board had:

• when providing Mr D with an interim report, failed to offer him free legal advice and the opportunity to jointly instruct an expert clinician to consider his mother’s care, in line with regulations[i]

• concluded that the failings identified were not the cause of his mother’s death, but failed to inform Mr D that this decision had been reached without her clinical records which it had misplaced.

The Ombudsman made several recommendations including that Mr D should be offered the
expert clinical and legal advice he was entitled to under the Putting Things Right process.

Commenting on the investigation, Nick Bennett, Public Services Ombudsman for
Wales, said:

“This was at best, a lack of transparency and at worst, an attempt by the Health Board to mislead, potentially jeopardising patients’ faith in the Putting Things Right process.

“This is exactly the type of poor complaint handling highlighted in my recent thematic report
Ending Groundhog Day: Lessons in Poor Complaint Handling. We need to move beyond this
fear and blame culture, and use the lessons from complaints to drive improvements to public
services in Wales.

“Whilst I cannot change the sad outcome for Mrs D, I hope that the Health Board will learn
from this experience and ensure future complaints are dealt with in a timely and
compassionate way.”