Report Date


Case Against

Cwm Taf Morgannwg University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Mrs B complained to the Ombudsman about the care and treatment that her late aunt, Mrs A was afforded by Cwm Taf Morgannwg University Health Board(“the Health Board”). Specifically:

a) Whether the support provided to Mrs A by the Macmillan nurses between April and June 2020was appropriate.

b) Whether the decision to discharge Mrs A from a Macmillian Specialist Palliative Care Unit (“the Unit”)on 4 June was appropriate. In addition, whether the discharge arrangements and care package were appropriate and sufficient to meet her needs.

c) Whether the decision not to admit Mrs A to the Unit between 6 June and her death on 15 June was appropriate (especially as it was her wish to end her life there).

The investigation found that the support provided to Mrs A by the Specialist Palliative Care Team (“SPCT” – a multidisciplinary team that includes Clinical Nurse Specialists) between April and June 2020 was appropriate. This aspect of the complaint was not upheld.

The investigation found that the decision to discharge Mrs A from the Unit on 4 June was appropriate. Mrs A’s symptoms were controlled, and she was comfortable prior to discharge. A24-hour nursing needs assessment and therapy intervention assessment was undertaken prior

to discharge; and the package of support in place, met Mrs A’s needs. There were failings in the discharge process; final checks were not undertaken to ascertain whether Mrs A could draw all her medications, she was not provided with the medications upon discharge, rather they

were delivered after her arrival home. Consequently, Mrs A was not able to self-administer her prescribed medications. Mrs A’s pain was not managed during transfer home and Mrs B described her as in pain and distressed upon arrival. This aspect of the complaint was partially upheld. The Health Board had revised its discharge checklist to address the issues outlined prior to the issuing of the final report.

The investigation found that the Palliative Care Consultant agreed admission to the Unit on 6 June, but it is unclear whether this message reached the nurses at the Unit. Admission was refused, and this was inappropriate. Mrs A and Mrs B must have felt confused and frustrated as well as disappointed by the actions of staff. Whilst it was Mrs A’s wish at times to end her life in the Unit (there is reference to her wanting to die at home), there is no absolute right to admission. At no stage of Mrs A’s admission to hospital was transfer to the Unit clinically indicated. The investigation did not find that Mrs A suffered a clinical detriment, as the care she was provided at the hospital was appropriate. The investigation found that it was not appropriate to deny admission on6 June.

The Health Board agreed to provide Mrs B with an apology for the failures outlined within the report and to pay a sum of £250 in recognition for the poor complaint handing and the injustice caused because of that.