Report Date


Case Against

Cwm Taf Morgannwg University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

The investigation found that the management and monitoring of Mr B’s INR leading up to the time at which surgery was still planned to go ahead was appropriate, however, this was not the case once the decision not to proceed with surgery was taken. Whilst it is uncertain whether the omission of one dose of warfarin had any major clinical impact on Mr B’s care, the uncertainty this has left Mrs A with is an injustice to her. This aspect of the complaint was upheld. The investigation found that there was a failure to maintain accurate nursing records, particularly in relation to Mr B’s vital sign observations. This service failing is an injustice and undermined Mrs A’s confidence that the care Mr B received was appropriate. This part of the complaint was upheld to that extent. The investigation also found that Mr B’s address being incorrect on his DNACPR form this did not have an adverse effect on his care and that the blood tests carried out were an appropriate part of Mr B’s treatment. It found, however, that overall medical recordkeeping for Mr B during his admission did not meet the standards required as part of good medical practice and this part of the complaint was also upheld. Finally, the investigation found that the CT scan was requested and reported upon in an appropriate and timely manner and in accordance with national guidance, so this aspect of the complaint was not upheld.