Report Date


Case Against

Cardiff and Vale University Health Board


Clinical treatment in hospital

Case Reference Number



Not Upheld

Ms C complained about the care provided to her father, Mr A, by Cardiff and Vale University Health Board (“the Health Board”) when he suffered an unwitnessed fall in the early hours of 10 August 2023. We investigated whether there were appropriate falls risk assessments and prevention measures in place for Mr A, and whether he was being monitored appropriately.
The Ombudsman found that all appropriate risk assessments were in place to consider Mr A’s personal risk of falling, including whether bedrails should be used. It was appropriate for him to have bedrails in place at the top of the bed (“half top bedrails”). The bed was at its lowest setting and a urine bottle and call bell were within Mr A’s reach. Mr A was not confused or disorientated, and he got out of bed independently. There was nothing further that should have been done to prevent Mr A’s fall. The complaint was not upheld.