Report Date


Case Against

Cwm Taf Morgannwg University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Ms A complained about the care and management her late father, Mr A, received when he attended the Emergency Department (“ED”) of Prince Charles Hospital (“the Hospital”) following a referral by his GP. This included the Acute Consultant Physician (“the Acute Physician”) failing to adequately investigate her father’s condition or diagnose his pneumonia. She said if this had happened, she felt that his death could have prevented. Ms A was also dissatisfied with the Health Board’s handling of her complaint.
The Ombudsman’s investigation found that clear opportunities to treat Mr A were missed during his ED attendance. The Ombudsman could not discount the possibility that had Mr A not been discharged, the cause of his lung infection could have been diagnosed and treated sooner with antibiotics. She concluded that the clinical shortcomings in Mr A’s care and management represented a serious service failure and that, as a result, Mr A and his family had been caused a significant injustice. It was not possible to know whether this would have resulted in a different outcome, however, that loss of opportunity had created uncertainty for the family. This aspect of Ms A’s complaint was upheld.
The Ombudsman was satisfied that the medical and nursing staff were aware of Huntington’s disease, and this did not delay Mr A being administered pain medication. However, the investigation found that Mr A did not undergo a pain assessment and therefore it was not possible to say definitively say that Mr A was not in pain at all times. The Ombudsman concluded that this was a failing in terms of basic nursing care and upheld this aspect of Ms A’s complaint.
The Ombudsman also identified poor record-keeping by the Acute Physician which contributed to an unsafe discharge and fell short of the expected requirements outlined in guidance produced by the General Medical Council.
The Ombudsman also found that aspects of the Health Board’s complaint response lacked depth and rigour and given the administrative failings identified made findings of maladministration in upholding these aspects of Ms A’s complaint.
The Ombudsman did not uphold Ms A’s complaint about nitrofurantoin, as it was a recognised medication to treat recurrent urinary infections and Mr A’s symptoms was not in keeping with the lung conditions Ms A had described nor did she identify issues with communication which the investigation concluded was reasonable and appropriate.
Amongst the recommendations the Ombudsman made was that the Health Board should apologise to Ms A and the family and carry out further actions to facilitate learning, such as sharing the report with its Clinical Director so the relevant clinicians could reflect on the findings, as well as the Quality and Safety Committee and Patient Safety Meeting.