Report Date


Case Against

Cardiff and Vale University Health Board


Clinical treatment in hospital

Case Reference Number



Early resolution

Mrs B complained that the Health Board had failed to properly consider her concerns about medication that was prescribed to her Aunt, Mrs C, during her admission to hospital in April 2020. Mrs C was prescribed morphine, despite being allergic to it, along with a sedative. Mrs B questioned whether this was appropriate given that the Medicines and Healthcare products Regulatory Agency (“the MHRA”) recommends extreme caution when prescribing those types of medication together.

The Ombudsman found that the Health Board’s complaint response was inaccurate and contradictory. It stated that Mrs C’s morphine allergy had not been identified but there was evidence it had been noted by a Triage Nurse. It also said initially that Mrs C was not given morphine, but then subsequently confirmed that 2 doses of Oramorph (liquid morphine) were given with no ill-effect. There was also no response to the concern that the prescriptions might have been contrary to the MHRA guidelines.

The Health Board agreed to write to Mrs B within 1 month to apologise for the poor complaint handling, offer £250 for her time and trouble pursuing the complaint and provide reassurance that lessons had been learned. It also agreed to specifically address the contradictions in the complaint response as well as the clinical implications and relevance of the MHRA prescribing guidelines and the 2 doses of Oramorph that were administered to Mrs C in the presence of a morphine allergy.

18 June 2022