Report Date


Case Against

Cwm Taf Morgannwg University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Mr X was 69 years old with a history of multiple sclerosis, a hiatus hernia and a previous pulmonary embolism. On 25 March 2019, following Mr X’s GP referral to the Royal Glamorgan Hospital (“the Hospital”) with confusion, delirium and queried lower urinary tract infection, he was admitted. Sadly, on 19 April Mr X died. Mrs X complained about Mr X’s treatment at the Hospital between 25 March and 19 April.

The Ombudsman found that Mr X’s treatment and his management on a respiratory ward were reasonable. She also found that he was assisted with diet and fluid, the nursing care was good and there was no criticism of the communication between nurses and doctors.

The Ombudsman found that failure to have administered salbutamol nebulisers, Betmiga MR medication was not administered and unavailable on 5 and 6 April, the lack of physiotherapy referrals and the conflicting views over Mr X’s last days of life were service failures and on that basis, she partly upheld the complaint.

The Health Board agreed to implement the Ombudsman’s recommendations and apologise to Mrs X for the identified failings within a month and within 3 months to review why Betmiga MR medication was unavailable, take steps to prevent a repetition and ensure consistent communication during a patient’s last days of life.