Report Date


Case Against

Cwm Taf Morgannwg University Health Board


Clinical treatment in hospital

Case Reference Number



Voluntary settlement

Ms C complained about the care and treatment her late father, Mr A, received when he was admitted to hospital on 2 occasions between 10 December 2021 and 14 January 2022. We considered whether communication with Mr A’s family, including around visiting restrictions, during his time in hospital, was sufficient and appropriate, whether Mr A was well enough to have been discharged from hospital and whether he should he have had a care plan in place. We also considered whether the use of haloperidol to treat Mr A was appropriate given the information provided to medical staff by Ms C, and whether a concern that Mr A may have ingested hand gel was investigated sufficiently and treated appropriately.

The investigation found that the communication with Mr A’s family was generally sufficient, and the investigation into the possible ingestion of hand gel was appropriate. It was not possible to establish whether medical staff acted against information provided by Ms C when issuing haloperidol, but Mr A’s agitation made sedation necessary. These elements of the complaint were therefore not upheld. However, the investigation found that elements of Mr A’s discharge were not in line with relevant guidance, the reversal of the previous rationale for keeping him as an inpatient was not sufficiently addressed, and, given his re-admission to hospital so soon after, there were concerns about the appropriateness of the initial discharge decision. This would have been distressing to him and his family and could have influenced his later deterioration. The Ombudsman therefore upheld this part of the complaint.

We recommended that the Health Board should provide Ms C with a written apology for the failings identified, and bring this report to the attention of the relevant medical and nursing teams and remind them that the Discharge Planning Policy and relevant NICE Guidance must be followed in all cases and in particular when the patient being discharged is elderly, frail and/or has social care needs.