Report Date


Case Against

Cwm Taf Morgannwg University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Mrs A complained about the appropriateness of the discharge arrangements following her mother-in-law (Mrs B’s) admission to hospital.

The investigation found that Mrs B did not meet the medical criteria for discharge as set by the Consultant and that a stairs assessment should have been undertaken prior to discharge. It also found that whilst Mrs B said her daughter would move in to help/assist following discharge, direct contact was not made with Mrs B’s family to clarify this arrangement or to give them the opportunity to ask questions about discharge. These complaints were upheld. The investigation found there was no requirement for an Occupational Therapy referral to have been made and that a repeat COVID-19 test was not necessary prior to discharge. Given the lack of documentary evidence it was not possible to determine if discussions were held with Mrs B around a package of support/care, however there was no clinical indication that any adaptions/equipment was required. These complaints were not upheld.

Whilst it was not a specific head of complaint, overall the investigation identified that the quality of record keeping by nurses on the ward was not in line with relevant guidance. The Health Board agreed to implement improvement action in this regard.The Health Board also agreed to:
• Provide Mrs A with an apology.
• Disseminate a circular to nursing staff to review relevant nursing guidance and to clinical staff to review guidance on how to calculate and accurately complete National Early Warning Score charts.

• Try to identify specific members of staff identified as not complying with record keeping standards, provide them with a copy of the report and ask them to reflect on their individual failures.
• Invite a member of the clinical staff to reflect on the report and discuss the findings at their next annual appraisal.
• Outline how it proposes to provide more effective communication with patients’ families around discharge planning (especially during a period whereby visiting is restricted) and how progress in this area will be monitored.