A word from Michelle

Welcome to the third edition of our newsletter.

Again, we bring you a quick and easy-to-digest summary of our recent work. Below, you will find our main complaints trends so far this year and summaries of our three new public interest reports. We also highlight opportunities from broader learning from one of our extended own initiative investigations as well as a recent outcome of a Code of Conduct referral.

Our Complaints

So far during 2023/24, we received 7,287 new cases – of which, 2,395 became duly made complaints.

Compared to this time last year, we are seeing increases in both complaints about public services and about the Code of Conduct. So far we have had 5% more complaints about public services and 18% more complaints about the Code of Conduct.

We also closed 7,382 cases – of which, 2,504 complaints. So far this year, we closed 190 investigations about public service complaints, 90% of which were about health. Public services complaints closures are up by 9%, and Code of Conduct complaint closures are up by 5%.

To see summaries of complaints we resolved early or investigated, see Our Findings.

Public Interest reports

Between August and December, we published 3 public interest reports.

Betsi Cadwaladr University Health Board (202004800)

Patient in care of Betsi Cadwaladr University Health Board suffered permanent sight loss and will need life-long treatment as a result of inadequate vascular services. Find more details here.

Cwm Taf Morgannwg University Health Board (202106392)

Deterioration and death of a patient with umbilical hernia might have been prevented had Cwm Taf Morgannwg University Health Board not missed two opportunities to appropriately admit him. Find more details here.

Betsi Cadwaladr University Health Board (202107105 & 202205543)

Patient in care of Betsi Cadwaladr University Health Board was left with health and mobility problems that might significantly limit her quality of life for years to come after failings in hospital admission for suspected appendicitis and subsequent treatment and care. Find more details here.

This report was an Extended Investigation.

An Extended investigation happens when we are already investigating a problem and we extend the investigation to other issues or complainants.

During the year we closed two extended investigations. We drew the following learning from the above report:


Mr B had complained about hospital care his wife, Mrs B, received after she developed appendicitis and had her appendix removed. The clinical adviser identified significant failings in post operative care which led to Mrs B having an avoidable cardiac arrest and needing several weeks in intensive care which had life-changing long-term impacts.  The adviser also identified that there was a missed opportunity 2 years before to arrange an appendicectomy in response to a scan result.  This would have avoided the later appendicitis. As Mr and Mrs B had been entirely unaware of this, we extended the investigation to address the issue using our own initiative powers. The original complaint and extended element were upheld and we agreed recommendations including significant financial redress.  We noted in the final report, which was released as a public interest report, that had we not started an own initiative investigation, this significant additional failing leading to serious injustice to Mr and Mrs B would not have come to light. We highlighted that this demonstrated why the own initiative power is needed, in the public interest, and for individuals who come to the Ombudsman.

Code of Conduct referrals

During the last quarter, we had decisions on referrals to Standards Committees.

1. Councillor Glyn Smith of Abertillery & Llanhilleth Community Council – Our report concerned a complaint that the Councillor had signed documents which resulted in excessive gratuity payments being made to the Council’s Former Clerk and Former Secretary, and that the Member failed to declare interests relating to the Former Clerk and the overpayments. The report on the investigation was referred to the Monitoring Officer of Blaenau Gwent County Borough Council for consideration by the Council’s Standards Committee.

The Standards Committee of Blaenau Gwent County Borough Council concluded that on the balance of probabilities the Councillor had, conducted himself in a manner which brought the office and council into disrepute, used his position improperly to create an advantage for another, used the resources of the Council unlawfully and failed to declare personal and prejudicial interests at appropriate times.

The Standards Committee decided that the most appropriate sanction to be applied was a censure, with a recommendation for further training in respect of the Members Code of Conduct, with a particular emphasis upon understanding the Code in order to prevent breaches arising in the future.

2. Councillor Robert Phillips of Abertillery & Llanhilleth Community Council – Our report concerned a complaint that the Councillor had signed documents which resulted in excessive gratuity payments being made to the Council’s Former Clerk and Former Secretary, and that the Member failed to declare interests relating to the Former Clerk and the overpayments. The report on the investigation was referred to the Monitoring Officer of Blaenau Gwent County Borough Council for consideration by the Council’s Standards Committee.

The Standards Committee of Blaenau Gwent County Borough Council concluded, based on the specific circumstances of this matter, that on the balance of probabilities the Councillor had not breached the code.

Our Business Plan and Key Performance Indicators

In April 2023, we published our Strategic Plan 2023-2026: A new chapter. To read the Plan, go here.

The Strategic Plan is a high-level document. However, we said at the time that we would produce an annual Business Plan for each year of the Strategic Plan.

We explained that that Business Plan would also include the Key Performance Indicators (KPIs) that we would use to monitor our performance and impact in areas that we can control or influence.

In September, we published our Key Performance Indicators and Business Plan Actions for 2023/24.

To read this publication, click here.

Homelessness Reviewed: Revisited

While our Own Initiative Investigation into carers needs assessment is ongoing, we took some time to publish a follow-up report on our previous, and first ever, investigation of that nature – Homelessness Reviewed: an open door to positive change (2021).

That investigation examined whether local authorities in Wales were meeting their statutory duties to ensure that homelessness assessments were carried out appropriately.  We became aware that a large proportion of these assessments were being challenged and overturned at review.

The 2021 report on the investigation identified some systemic issues relating to the administration of these assessments at the three Investigated Authorities: Cardiff Council, Carmarthenshire County Council and Wrexham County Borough Council.

As a result, we made several recommendations to these Authorities. For wider learning, we invited the Welsh Government and the other 19 non-investigated authorities in Wales to consider the impact of the findings on homelessness services locally and to take action to improve homelessness services across Wales.

Our follow up report on the progress made shows that

  • there has been a year-on-year increase of 10% in homelessness assessments being completed by Welsh local authorities.
  • there has also been an increase in the percentage of assessments leading to a review. Although unexpected, this increase could also be due to more awareness of the option to challenge the assessment results.
  • positively, compared to 2017/18, a smaller proportion of assessment decisions were seen to be overturned on review. This could be evidence of improved and more consistent decision making. However, the proportion of reviews overturned remains high and has not improved since 2021.
  • some reasons why assessment decisions are still being overturned at review continue to be that there has been a change in circumstances, the property offered did not meet needs or that more investigation was required.

Positively, Welsh local authorities were able to demonstrate to us many improvements – for example, that

  • homelessness officers across Wales have received more relevant training
  • there has been more use of alternative communications methods (with use of video calls and chatbots currently explored by some local authorities)
  •  some key communication resources have been reviewed to ensure they are available in an accessible format.

However, it is disappointing that not all the 19 non-investigated authorities have considered potential service improvements in light of our first Own Initiative report.

To read this publication, click here.

Our new Equality Plan

In November, we published our new Equality Plan. Under the Plan, we will:

  • Ensure that we support people with additional access needs to use our complaints service.
  • Help to improve our services and impact through better engagement with equality groups.
  • Raise public awareness of the office and its role and powers among groups under-represented among our complainants.
  • Maintain and develop more accessible information explaining who we are and how we work.
  • Through our Complaints Standards role, seek to influence positively the accessibility of local complaints processes.
  • Work to improve representation of target groups among our workforce.
  • Continue to monitor our gender pay gap and identify any opportunities to reduce it further.

We are grateful to all who contributed to creating this Plan and are looking forward to putting it to work!

Read our plan here.

Equality and Human Rights Casebook

We published our fifth Equality and Human Rights Casebook, which contains a selection of cases considered by us involving equality and human rights considerations.

Some of these complaints still related to events that unfolded during the COVID-19 pandemic and during the measures and restrictions introduced to protect public health.  Continuing the theme introduced in the previous years, the publication includes 2 cases related to the application of the ‘Do Not Attempt Cardiopulmonary Resuscitation’ procedure.

In addition, several further cases related to healthcare and housing highlight how Failings of public service providers may have engaged human rights duties, or the FREDA principles of Fairness, Respect, Equality, Dignity and Autonomy – core values which underpin human rights.

The selection in the Casebook also includes some complaints related to equality duties – predominantly, the duty to offer reasonable adjustments to disabled people. However, there is also one example of a complaint concerning services for trans people.

Read our Casebook here.

Complaints Standards data for 2023/24 to date

In December, we published statistics on complaints received by Health Boards and Trusts, and local councils in Wales during the first half of the 2023/24 financial year.

Click here for detailed data.

Our communications and engagement work

Under our new Communications and Engagement Strategy as well as the Equality Plan, we have stepped up our efforts to raise awareness of who we are and how we can help among diverse communities.

Over the recent months, we used opportunities to promote improvement and raise awareness of our office at

  • Mastering Diversity Conference, organised by a member of our Advisory Panel, Bernie Davies
  • Health Fair, organised by Race Equality First
  • Carers Wales National Conference
  • The National Tenant Engagement Conference for Wales 2023
  • A joint awareness-raising event with Settled, a charity supporting EU citizens in the UK.

We also presented our work at the meeting of the Gwent Citizen’s Panel.

In addition, we have been taking steps to improve how accessible we are:

  • A new page on our website now outlines how we can help people to use our service.
  • We have now published on our website a list of advice and advocacy bodies that may be able to support people who want to complain to us or another organisation. It is a live document – we will be updating it regularly and adding more organisations over time. To see the list, click here.
  • We also offered training on our process to Llais, Newport Gwent constituency offices and RNIB.

We would like to understand what prevents people from using our complaints service in Welsh. We have therefore launched a public survey, asking all our service users who have been in contact with us over the last 3 years and have any level of Welsh ability of their experience of using, or considering using, our service in Welsh. Our Welsh Language Survey is available here.

To join the press list for PSOW news, email us at communications@ombudsman.wales.