Report Date


Case Against

Cardiff and Vale University Health Board


Clinical treatment in hospital

Case Reference Number



Early resolution

Mrs A complained about her late husband’s inpatient management and care after he fractured his left ankle, as well as communication with the family during his inpatient admission at Llandough Hospital and University Hospital of Wales between December 2022 to February 2023. Sadly, Mr A died on 16 February.

Mrs A also expressed dissatisfaction with the Health Board’s handling of her complaint including its withdrawal of an offer to meet the family made in its complaint response.
The Ombudsman concluded that an investigation would not achieve much more, given that the independent Medical Examiner’s Service had not identified any clinical failings.

The Ombudsman noted that the Health Board had acknowledged and apologised for the considerable delay in responding to Mrs A’s complaint which it said was due to the Service experiencing unprecedented demand and which had impacted on its ability to respond in a timely manner. Given the shortcomings in the Health Board’s complaint handling, the Ombudsman was critical that the Health Board had withdrawn its offer to meet Mrs A and the family.

The Ombudsman took the view that in the circumstances, this was not appropriate and was satisfied that this, along with the delay, would have further added to the family’s distress.

The Health Board as part of an early resolution agreed that within 6 weeks it would write to the family and provide them with an opportunity to meet with the Health Board to discuss their concerns around communication. It would also update the family on lessons learnt from Mr A’s case and review its complaint handling process. This was to ensure that offered meetings were not rescinded when complainants took up the offer to meet.