Report Date


Case Against

Cwm Taf Morgannwg University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

We investigated concerns raised by Mr A in relation to his wife, Mrs A’s, treatment in Hospital.

The investigation found that Mrs A’s treatment during her 2 admissions to hospital was appropriate for her presenting symptoms and in line with relevant guidance, that it was reasonable that her liver cancer was not identified earlier, and that her nursing care was appropriate. These elements of the complaint were therefore not upheld. The investigation found that while the medication provided was largely appropriate, once it was identified that Mrs A was in the last days of her life (i.e. nearing death), implementing a relevant care pathway could have more proactively monitored any pain medication she may have benefitted from. Similarly, while unfortunately there were no single rooms available for Mrs A, the investigation found that her family should have been informed that she was likely to die as soon as this was established by relevant medical staff and allowed to visit from this time (approximately 4 hours earlier). These complaints were therefore partly upheld. Finally, the investigation found that elements of the complaint handling were unsatisfactory, and caused unnecessary further distress to Mr A, which was an injustice to him and this element of the complaint was upheld.

The investigation recommended that the Health Board should apologise to Mr A for the identified failings, and remind relevant staff of the importance of identifying patients in the last days of life, contacting their next of kin, and putting appropriate care protocols in place as soon as possible. It also recommended reminding staff involved in complaints handling of the importance of ensuring accurate handling of relevant information and to consider methods that could be implemented to reduce the risk of similar errors occurring.