Report Date


Case Against

Cardiff and Vale University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Mr B raised numerous complaints on behalf of his late mother, Mrs A, about her care and treatment over the course of 3 admissions to the University Hospital Llandough (“the Hospital”) between August and October 2019.

The Ombudsman found that Cardiff and Vale University Health Board (“the Health Board”) failed to provide appropriate standards of nursing care because of a lack of individualised care planning, evidenced based interventions and regular nursing evaluation. Consequently, from the time of Mrs A’s second admission, appropriate steps were not taken to manage her longstanding leg ulcer and lymphoedema (blockage of the lymphatic system). In addition, there were no arrangements in place to provide continuity of ulcer care with the specialist pressure bandaging that was being applied in the community. This put Mrs A at increased risk of the serious deep tissue infections that she went on to develop. On Mrs A’s discharge from the second admission, an assessment for home care support failed to consider the previous level of input provided and her increased care needs. A reduced number of care visits was arranged leaving Mrs A’s family struggling to cope with an inappropriate level of support for 6 days before matters were addressed. Mrs A also had unmet nursing care needs during her final admission related to pressure and pain relief, personal hygiene and hydration.

The Ombudsman also found that medical staff inappropriately delayed end of life care planning and communicating the incurable nature of Mrs A’s cancer diagnosis to her family until she was in the last few days of her life. When seeking her consent for participation in a medical study, the discussion with Mrs A was not recorded by medical staff as per the relevant guidance. Consequently, the Ombudsman could not say with certainty that Mrs A’s written consent was valid given the evidence that she was experiencing episodes of confusion at the time.

The Ombudsman did not uphold complaints relating to the provision of antibiotic therapy which he found was prescribed in accordance with clinical guidelines. He also found that safeguarding concerns were responded to appropriately.

The Health Board agreed to apologise to Mr B, and to make him a redress payment of £1,750 in recognition of the failures identified and the unnecessary distress caused. The Health Board also agreed to share the findings of the report with relevant staff in order to promote organisational learning, to provide training on pressure ulcer prevention, wound management and care assessment and planning to nursing staff, to review the hospital processes and resources around wound management, and to put in place a mechanism to ensure that inpatients assessed as needing pressure bandaging are provided with it.