Report Date


Case Against

Cwm Taf Morgannwg University Health Board


Admissions/discharge and transfer procedures

Case Reference Number



Early resolution

Mrs P complained that the Health Board failed to provide appropriate mental health care for her late sister, Mrs Q, at Royal Glamorgan Hospital and did not properly assess her mental capacity before her discharge home on 20 January 2021. She complained that the decision to discharge Mrs Q was not appropriate, taking into account concerns about her ability to look after herself, that she did not have a working phone and that her house was in a very poor state of repair. She also complained that the Consultant Psychiatrist responsible for Mrs Q’s care failed to take appropriate action after visiting her at home on 9 February. She felt that these failings contributed to the deterioration of Mrs Q’s health which led to her death on 20 February.

The Ombudsman was concerned that the Health Board had not completed a number of actions that it had undertaken to carry out. In settlement of the complaint, the Health Board agreed a series of actions, including to hold a meeting with the family to discuss their concerns with the medical team involved in Mrs Q’s care and subsequently to provide a final response under the Putting Things Right complaints process.

The Ombudsman considered that the actions agreed provided a reasonable opportunity to resolve the complaint.