Report Date


Case Against

Cwm Taf Morgannwg University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Mrs C complained about the care of her aunt, Mrs D, who was admitted to Royal Glamorgan Hospital and where, shortly before Mrs D died on 11 January 2021, a suspected deep tissue injury (“SDTI”) was identified to her sacrum and buttocks, which was investigated as a safeguarding issue. Mrs C complained about failures to manage Mrs D’s pressure relieving care appropriately during her time in hospital or to share information, promptly and appropriately with her family about the safeguarding issue and its investigation.

The Ombudsman found that Mrs D was not repositioned as frequently as she should have been and that there were unexplained gaps in her records about when her pressure care was assessed and addressed, resulting in a SDTI which was unacceptable and avoidable. The failures in care were appropriately escalated through the Health Board’s internal procedures, but there were delays in informing Mrs D’s family of the outcome of that process and they had to chase the Health Board for news. The Ombudsman upheld both elements of the complaint.

The Ombudsman recommended that, within one month, the Health Board should apologise to Mrs C and make a financial redress payment of £750 to acknowledge the distress caused by the failings identified and to recognise the family’s time and trouble in having to chase the outcome of the safeguarding investigation. The Ombudsman also recommended that the Health Board should remind its staff that repositioning should continue for end of life patients, unless the risks outweigh the benefits, and that this decision should be agreed with the patient, and/or their carer and documented in care records.