Report Date


Case Against

Cwm Taf Morgannwg University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Mrs X complained about the care provided to her mother, Mrs Y, at Prince Charles Hospital Emergency Department (“the ED”) in September 2020.
The Ombudsman found that Mrs Y’s initial assessment at the ED was within the range of appropriate clinical practice. However, despite triggering the sepsis pathway on admission, there was a delay in following the pathway and in administering antibiotics. There were several other shortcomings including ad hoc monitoring of vital signs and a lack of documentation of Mrs Y’s care for a number of hours. The Ombudsman upheld the complaint that there was a failure to provide appropriate care to this extent. However, Mrs Y’s chances of survival were very poor and therefore the failure to follow the sepsis pathway would not have affected the sad outcome.
The Ombudsman found that communication with Mrs X about her mother’s condition could have been better, notwithstanding the impact of the COVID-19 pandemic; she was not consulted about her mother’s presentation on admission and neither was she told of the seriousness of her mother’s condition early on. The complaint about poor communication was upheld.
The Ombudsman found that based on Mrs Y’s presentation on arrival at the ED, it was appropriate to take a COVID-19 swab. However, the records did not allow him to determine when the positive result was available and whether consideration had been given to treatment. He also found that there were shortcomings in record keeping.
The Ombudsman found that, overall, the DNACPR decision was, on balance, clinically appropriate and both Mrs Y and Mrs X were consulted.
The Health Board agreed to take a number of actions including providing feedback to relevant staff in relation to the identified shortcomings and updating the Ombudsman on the ED action plan for improvement work and any action taken as a result of any systemic concerns identified regarding identification and treatment of sepsis.