Report Date


Case Against

Cwm Taf Morgannwg University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Dr A complained about the dementia treatment and care provided by the Health Board to her mother, Mrs B, between March and December 2020. In particular, she complained that the Health Board failed to review and monitor Mrs B’s condition appropriately while face-to-face appointments were suspended, did not promptly and appropriately consider whether to prescribe medication to Mrs B and failed to communicate with her father, Mr B, adequately about Mrs B’s care and where and how he could access appropriate support.

The investigation found that an opportunity was missed to review Mrs B in a timely manner and that this failing resulted in uncertainty for her family as to whether earlier medical review could have made a difference to her condition or its progression. This was an injustice to Dr A and her family. This complaint was upheld. The failure to carry out an appropriate review for Mrs B also resulted in a missed opportunity to consider possible treatment strategies, which might have included medication. This again resulted in uncertainty and distress for her family, which was an injustice. This element of the complaint was upheld. Finally, the investigation found that information about support services was provided to Mr B. This part of the complaint was therefore not upheld.

The Ombudsman recommended that the Health Board should, within 1 month, provide Dr A with a written apology and £250 redress for the time and trouble of pursing her complaint. It was also recommended that within 3 months, the Health Board should share the report with the clinical staff involved in Mrs B’s care, share the findings more widely at an appropriate clinical forum and review the way in which diagnostic tools are used to inform the care of patients with mild cognitive impairment and Alzheimer’s disease. The Ombudsman recommended that within 6 months the Health Board should develop a robust escalation policy and procedure for medical reviews in cases such as Mrs B.