Report Date


Case Against

Cwm Taf Morgannwg University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Ms J complained that her father, Mr T, was inappropriately discharged from hospital without having seen a kidney specialist and without full investigations having been carried out, that there were failings in the care and treatment provided to Mr T during a second admission, and that the reasons for his confusion were not properly investigated. In addition, Ms J complained that despite her father being frail and unsteady, staff failed to take steps to protect him from falling and he suffered 3 falls during his second admission, only 2 of which were mentioned to his family. Ms J further complained that medical staff put a “do not attempt cardio-pulmonary resuscitation” (“DNACPR”) order in place without consulting Mr T’s family.

The Ombudsman did not uphold the complaint that Mr T was inappropriately discharged from his first hospital admission. The Ombudsman found that his kidney problems were appropriately investigated and treated, and that whilst he was not seen by a kidney specialist during his admission, he was discussed with the renal team the day after his discharge and appropriate follow up arrangements were made. The Ombudsman also found that Mr T’s symptoms were appropriately investigated and treated during his second admission, and did not uphold the complaint.

The Ombudsman upheld the complaint that staff failed to take appropriate action to reduce the identified risk of falls and found that his family should have been informed of all his falls. These failings caused distress and discomfort to Mr T and additional anxiety to his family.
The Ombudsman found that the DNACPR decision was clinically appropriate, and that there was no requirement to consult Mr T or his family beforehand. The Ombudsman did not uphold the complaint.

Please Note: Summaries are prepared for all reports issued by the Ombudsman. This summary
may be displayed on the Ombudsman’s website and may be included in publications issued by the
Ombudsman and/or in other media. If you wish to discuss the use of this summary please contact the
Ombudsman’s office.

The Ombudsman recommended that within a month of the report, the Health Board apologise to Ms J. The Ombudsman further recommended that within 3 months of the report, the Health Board should carry out an audit of falls prevention documentation for patients judged to be at high risk of falling, and provide evidence of the outcome.