Report Date


Case Against

Cwm Taf Morgannwg University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Mrs J complained about the following aspects of the care her late husband, Mr J, received in Prince Charles Hospital:
• The prescription of codeine.
• Whether Mr J should have received intravenous albumin sooner.
• Whether Mr J received appropriate IV fluids.
Mrs J also complained:
• About the delay in Mr J being seen by a nephrologist between 2016 and 2019.
• That Mr J was not told about gallstones found on a scan in 2019.
The Ombudsman found there was nothing recorded in Mr J’s records to suggest he should not have been prescribed codeine. It was not appropriate to have given Mr J albumin earlier as he did not have liver failure. The Ombudsman found that any delay in Mr J being seen by a nephrologist did not have a significant impact on his condition. The gallstones were an incidental finding on the scan, and had no effect on Mr J’s treatment or outcome, and thus the failure to inform him did not cause Mr J any injustice. The Ombudsman did not uphold these elements of the complaint. However, he upheld the complaint about IV fluids, as there was no record of Mr J having been given fluids on some days, which was an injustice to him, and incomplete completion of relevant charts on others.
The Health Board agreed to apologise to Mrs J for the failings, to review its policy for removing patients from its list (relating to the delay in Mr J being seen by a nephrologist) and to arrange refresher training for staff on caring for patients requiring fluid therapy.