Report Date


Case Against

Cardiff and Vale University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Miss C complained about the care and treatment her late mother, Mrs A, received from Cardiff and Value University Health Board. Specifically, she complained that care and management of Mrs A’s leg wound was not of an appropriate standard during November and December 2021, prior to her admission to the University Hospital of Wales (“the First Hospital”). She also complained that diagnosis, treatment and care whilst Mrs A was an inpatient at both the First Hospital and Llandough Hospital (“the Second Hospital”) was not of an appropriate standard. She said discharge planning, care and management was inadequate for the period between Mrs A’s discharge from the First Hospital and her admission to the Second Hospital, and that communication with Miss C (Mrs A’s carer) was poor at both Hospitals.

The investigation found that the care and management of Mrs A’s leg wound prior to her admission was of an appropriate standard, as was communication with Miss C at both Hospitals. However, the diagnosis, treatment and care during Mrs A’s first admission fell below an appropriate standard, as did discharge planning, care and management.

The Ombudsman recommended the Health Board should apologise to Miss C for the failings identified in this report. She also said the Health Board should remind nursing staff of the requirements for care of patients who have vulnerable pressure areas and remind district nursing staff and ward nursing staff regarding the care of patients at risk of wound infection. Finally, she recommended the Health Board should remind occupational therapists to review the Royal College of Occupational Therapist Falls guidelines regarding home visit good practice.