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, an independent advocate from Llais Cymru, supported Mrs B to make a complaint about the care and treatment provided to her late husband, Mr B, when he attended the Princess of Wales Hospital in 2022. The investigation considered whether Mr B was placed on an appropriate ward following his admission via the Emergency Department (“the ED”) and whether Mr B should have been transferred to a ward specialising in mental health care at any stage during his admission. It also considered whether Mr B was over medicated with sedatives during his stay on the initial ward he was admitted to (“the First Ward”) and whether Mr B’s dignity was preserved during his time on the First Ward.

The investigation found that Mr B was not admitted to an appropriate ward from the ED. This complaint was upheld. The investigation found Mr B was appropriately transferred to a second ward and, due to him unfortunately contracting COVID-19, it was appropriate that he remained on this ward. This complaint was not upheld. The investigation also found appropriate safeguards were not in place to protect Mr B when staff administered intramuscular (“IM”) injections and that there was insufficient evidence that Mr B’s dignity was maintained on the First Ward. These complaints were also upheld.

The Health Board agreed to apologise to Mrs B for the failings identified, share the findings of the investigation with relevant clinicians, and provide evidence of training for relevant staff on the First Ward in regard to administering IM injections, liaising with mental health professionals and ensuring safeguards are in place to protect patients’ rights. The Health Board also agreed to provide evidence of an updated policy in relation to IM injections which considers both Mental Health and non-Mental Health settings.