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 on behalf of her husband Mr B, abou this treatment and care at the Princess of Wales Hospital (“the Hospital”) following an admission for treatment of a spinal fracture. Specifically, Mrs A said that the Health Board inappropriately prescribed morphine (an opiate painkiller) for Mr B after being advised that he was sensitive to it and that management of his spinal fracture with a back brace caused him severe discomfort and a further fracture to his sternum. Mrs A also raised concerns about the Health Board’s failure to meet Mr B’s nutritional needs, to arrange appropriate care and support on his discharge, and to communicate with her about his condition and plans of care.

The investigation found that Mr B’s sensitivity to morphine had been noted and that he was prescribed appropriate alternative pain medication. The management of Mr B’s spinal fracture with a back brace was also appropriate and the fracture to his sternum was more than likely due to his underlying health condition which caused bone weakness. However, the Health Board was slow to respond to Mr B’s reports of pain from use of the back brace and to review its suitability.

There was also alack of evidence in relation to nutritional assessment, monitoring and actions taken to improve Mr B’s oral intake when it was noted to be poor, and of appropriate escalation of his care when his constipation did not resolve. This was concerning as Mr B vomited faecal matter as a likely complication of his constipation which he breathed in causing a significant lung infection and a longer hospital stay. Finally, the investigation found that there was a failure by medical staff to communicate effectively with Mrs A about a deterioration in Mr B’s condition and that appropriate nursing assessment and planning with Mrs A for his discharge did not take place.

The Ombudsman recommended that the Health Board should apologise to Mrs A, and pay her £500for the failures identified and distress caused. The Health Board was asked to provide refresher training on completion of nursing documentation relating to nutritional needs, constipation care and discharge planning, to ensure that nursing care plans assisted staff to evidence effective communication with family members, and to share the findings of the report with medical staff and remind them ofthe importance of effective communication with family members in supporting their experience and perception of care.