Report Date


Case Against

Cardiff and Vale University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Mrs X’s complaint related to the care and treatment that her late husband, Mr X, received during his admission to the University Hospital of Wales in November 2020. Specifically, Mrs X complained that a Do Not Attempt Cardiopulmonary Resuscitation (“DNACPR”) form was inappropriately placed on her husband’s records against her wishes and without her permission. She also complained that the decision to stop active treatment, and move to end of life care, after only 3 days of her husband’s admission was inappropriate and premature, and that he was intentionally given morphine to overdose him and hasten his death. Mrs X said that the Health Board failed to give sufficient consideration to her views on these decisions. Finally, Mrs X also complained that her husband was not discharged from hospital to allow him the opportunity to die peacefully in his care home and that she was contacted by the Health Board’s Bereavement Team several months after his death.

The Ombudsman concluded that the DNACPR decision was appropriately made and that the decision to change to end of life care on 23 November was a reasonable one as, sadly, Mr X’s condition had deteriorated despite receiving appropriate treatment for COVID-19pneumonitis. The Ombudsman also found that the medications, including morphine, that Mr X was subsequently prescribed were appropriate and that there had been an appropriate level of communication with Mrs X in relation to these decisions. In addition, the Ombudsman considered that it would not have been possible for Mr X to have been discharged back to his care home due to the speed of his deterioration and in the context of the COVID-19 pandemic. As a result, the Ombudsman did not uphold these complaints. However, the Ombudsman upheld Mrs X’s complaint relating to the Bereavement Team as the Health Board accepted that the bereavement support service set up during the pandemic should have contacted Mrs X far sooner than April 2021. The Health Board explained that staffing issues had meant that the support service had been unable to meet its usual timeframe of contacting family members and provided the Ombudsman with information about the percentage of cases that were now meeting the relevant timescales. As the Health Board had already provided Mrs X with an apology and an explanation for this delay, the Ombudsman made no further recommendations.