Report Date


Case Against

Cardiff and Vale University Health Board


Clinical treatment in hospital

Case Reference Number



Voluntary settlement

Mr A complained about the way in which the Health Board communicated with the family during his late wife’s inpatient stay from 1 June 2022, given the family had a Lasting Power of Attorney (LPA). Mr A also had concerns about the X-ray changes in his wife’s shoulder region following a fracture and whether this had been caused by the mishandling of his wife by Health Board staff.
From a review of Mrs A’s medical records, the Ombudsman found it disappointing that the level of engagement with the family between 3 June to 12 July did not suggest that due consideration had been given to their legal LPA status and the implications of this, particularly given Mrs A’s later poor prognosis. This would have caused the family an injustice. The first demonstrable consideration of the LPA in the records had not occurred until 13 July.

The Ombudsman noted the Health Board’s comments that there was no indication that the care provided had an adverse effect on Mrs A’s shoulder fracture. The Health Board also acknowledged that a meeting with another orthopaedic consultant to consider Mrs A’s X-rays had been suggested but regrettably not progressed. It added that its Orthopaedic Team had offered their apologies for this omission and for the poor impression the family had been left with as a result.

The Health Board as part of a settlement agreed that it would write to the family to arrange a meeting with them and the Clinical Director of Trauma and Orthopaedics. The meeting would discuss the X-rays and address questions that the family might have. In addition, the process and timescale for the family to receive the X-ray images would be provided to the family. The Health Board also agreed to provide details of the changes in the LPA process that it had introduced as a result of Mr A’s complaint. It would also review how it documented LPAs to improve their visibility on a patient’s medical records as well as identifying a system for ensuring LPA documentation is followed up and present on the records. Finally, if it did not already do so, the Health Board would arrange appropriate training for staff around LPAs and its relevance in terms of clinical decision-making.