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 that the Health Board failed to appropriately manage her father’s (“Mr B”) pain, to accurately maintain his clinical records and to deal with the certification of his death in a timely manner.
The Ombudsman found that there were inappropriate delays in administering end-of-life anticipatory pain relief and in providing a syringe driver that were contrary to the relevant clinical guidelines. The record keeping failed to meet appropriate standards as there were significant gaps in Mr B’s records, including a lack of nursing records on the morning of his death. There was also a failure to follow the correct guidance in the emergency period allowing any doctor to complete and issue a death certificate to avoid unnecessary delays. These failings caused significant distress and uncertainty around the appropriateness of Mr B’s pain management for his family and their complaints were upheld.
The Ombudsman recommended that, within 1 month, the Health Board should apologise to Mrs A for the failings identified and make a redress payment of £500 in recognition of the distress and uncertainty caused. The Ombudsman also recommended that, within 3 months, the Health Board should provide evidence that it had reminded relevant staff members of the importance of ensuring that pain scores are recorded as part of routine observations, and of keeping full and complete records around medication prescribing and administration including documenting the rationale behind any changes to planned care. The Health Board should also review its process for the completion of death certificates.