Report Date


Case Against

Cardiff and Vale University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

The Ombudsman investigated a complaint from Miss C, on behalf of her mother-in-law Mrs B, about care and treatment that Mrs B’s late husband, Mr B, received from the Health Board during his hospital admission in May 2022. She complained that Mr B’s personal care and continence needs were not met, that his medication was not administered appropriately, and that medical staff failed to properly investigate and treat Mr B’s infection. She also complained that Mr B was discharged from hospital without a reasonable discharge assessment, resulting in his re-admission to a separate hospital within 48 hours. The investigation also considered whether the hospital failed to implement a Deprivation of Liberty Safeguard (“DOLS”) to ensure that Mr B was being lawfully detained and whether it took his diagnosis of post-traumatic stress disorder (“PTSD” – an anxiety disorder caused by very stressful, frightening or distressing events) into account.

The investigation found that Mr B’s personal care and continence needs were not met and did not reach acceptable standards. This compromised Mr B’s privacy and dignity and was an injustice to him. The investigation found that Mr B’s pain relief medication was appropriately reviewed and administered. However, medication prescribed for agitation(a state of anxiety or tension) was not administered and there was no reason for this, given Mr B’s preexisting PTSD and ongoing agitated state. These complaints were therefore upheld.

It was determined that the investigation and treatment Mr B received for his infection was appropriate and the standard of clinical care was acceptable. Mr B was also appropriately discharged, having received appropriate clinical review. These complaints were not upheld.