Report Date


Case Against

Cwm Taf Morgannwg University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Ms E complained about the care and treatment given to her late sister, Mrs F, from September 2019 up until her death in July 2020. Ms E said that Mrs F was left without dentures during this period which caused a serious deterioration in her health and significant weight loss that was not addressed, the District Nursing Team did not provide a bedpan for Mrs F when requested, Mrs F’s wishes about where she wanted to live were not taken into consideration prior to 2 hospital discharges in October 2019 and January 2020, and Ms E was unhappy at the length of time it took to respond to her complaint.
The Ombudsman’s investigation found that the deterioration in Mrs F’s health was due to her failing medical condition and dysphagia. There was no clear evidence to suggest that, had Mrs F had her dentures, her condition would either not have deteriorated or improved. This element of the complaint was not upheld.
The Ombudsman was unable to reach a finding in relation to whether the District Nursing Team did or did not provide a bedpan. There was no record of Ms E requesting a bedpan, and there was no record of the District Nursing Team advising Ms E that it did not provide bedpans.
The Ombudsman, however, found that Mrs F’s wishes about where she wanted to live prior to the 2 hospital discharges in October 2019 and January 2020 were not acted upon. The Ombudsman acknowledged that matters were complicated because Mrs F was challenging a Lasting Power of Attorney (“LPA”) (which was not in force at the time of the October discharge), Mrs F underwent several capacity assessments that assessed her at various times as having capacity and then not having capacity and the Health Board did not ask Mrs F where she wanted to live before both discharges. These were service failures and caused Mrs F the injustice of not being consulted about where she wanted to be discharged. The Ombudsman upheld this part of the complaint.

With regard to the delay in responding to Ms E’s complaint, the Ombudsman was satisfied that whilst it took the Health Board 9 months to respond to Ms E’s concerns, her complaint was complex and Ms E was kept updated regularly during this time. This part of the complaint was not upheld.
The Ombudsman recommended that the Health Board apologise to Ms E for the failings identified and share the report with the staff involved in Mrs F’s care and use it as a case study to consider the issues surrounding LPAs, capacity and ensuring the views of patients are considered prior to discharge. The Health Board agreed to the recommendations.