Report Date


Case Against

Cwm Taf Morgannwg University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Mr H complained about the care and treatment his mother, Mrs K, received at 2 hospitals between October 2019 and her discharge home in March 2020. In particular, Mr H was unhappy with the treatment Mrs K received while on Ward B2 which included a delay in completing and submitting a Deprivation of Liberty Safeguarding application for Mrs K (“DoLS” – an amendment to the Mental Capacity Act (“MCA”) to ensure that those who cannot consent to their care arrangements in a hospital are protected if those arrangements deprive them of their liberty), the failure to give Mrs K the flu vaccine, the protracted safeguarding process that delayed Mrs K’s discharge, and the amount of times Mrs K was moved and the poor communication with Mr H and his family.
The Ombudsman found that record keeping on the ward in question fell below the required standard and was not in accordance with relevant guidance, which meant when Mrs K was moved the receiving ward did not have all the information it needed. There was also an inexplicable delay in filling in a DoLS application which caused Mrs K and her family uncertainty and anxiety. The Ombudsman was also of the view that there was at times poor communication between staff and Mrs K’s family and a delay in completing Mrs K’s medicine reconciliation within 24 hours of her admission led to anxiety and unnecessary medication changes later in Mrs K’s admission. The Ombudsman also found that there was no record of a discussion about whether Mrs K had received the flu vaccine prior to admission as during her inpatient stay she did not receive the vaccine. The Ombudsman upheld these elements of the complaint.
However, he did not uphold the complaint about the protracted safeguarding process. Whilst this process meant Mrs K stayed in hospital for a longer period and she had less time at home before she died, the safeguarding process was necessary so the allegations could be investigated thoroughly.

The Ombudsman recommended a fulsome apology to Mr H and his family for the identified failings. He also recommended that his report be shared with all staff on Ward B2 and that the Health Board share details of the new handover documentation it had created and provide an update in relation to its new digital documentation system that would identify when DoLS applications/care plans were not filled in.

The Ombudsman also recommended that the Health Board undertook an audit of DoLS applications over the previous 24 months to identify if there had been any other delays, and if so what action it intended to take. Finally, the Ombudsman recommended that an audit of patient records should be carried out to determine if anyone else had not received the flu vaccine, and what action it intended to take based on its findings.
The Health Board agreed to all the recommendations.