Report Date


Case Against

Cardiff and Vale University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

. The complaint related to care provided to Mrs C, a tetraplegic patient, during a hospital admission in April/May 2022 at the University Hospital of Wales (“the Hospital”).

The Ombudsman found no concerns in relation to the medical care provided to Mrs C and did not uphold the complaint about the decision to discharge her. However, the investigation found that clearer information about her ongoing care could have been provided, on discharge, to carers and family. The complaint about discharge arrangements was therefore upheld to that limited extent.
The investigation also identified inconsistences in the manner that Mrs C’s fundamental care needs were assessed and documented in the care plans. Detailed information provided on admission about Mrs C’s needs and preferences was not always properly translated into the care plans. This meant that there were occasions when care was not tailored to Mrs C’s specific needs. This element of the complaint was upheld.

The Ombudsman recommended that the Health Board should provide an apology to the family, and an opportunity for them to share their experiences with Health Board staff. The Health Board confirmed it was currently evaluating how to improve its provision of individualised care to patients with complex physical needs. It agreed to complete this within 4 months and share a copy of the evaluation, and any associated action plan, with the Ombudsman’s office. A copy of the Ombudsman’s report was also to be provided to the Health Board’s Equalities Lead.