Report Date


Case Against

Cwm Taf Morgannwg University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Mr A complained about the care and treatment provided to his late wife, Mrs A, by Cwm Taf Morgannwg University Health Board at the Princess of Wales Hospital (“the Hospital”) between 9 December and 15 December 2020.

The Ombudsman found that the nursing care provided to Mrs A at the Hospital fell below expected standards. The available nursing documentation failed to provide assurance that Mrs A’s nutritional, toileting and skin care needs had been met. As a result, Mrs A may have experienced avoidable hunger, discomfort and distress. The investigation also found that there was a failure by nursing and medical teams to take prompt action when Mrs A’s condition began to deteriorate. This meant that there was an excessive delay in providing senior review and administering antibiotics. For these reasons, the complaint was upheld.

The Health Board agreed to the Ombudsman’s recommendations. These included to apologise and pay £1,000 to Mr A to reflect the distress caused by the failings identified. The Health Board also agreed to arrange for the investigation report to be discussed at appropriate clinical governance meetings for both nursing and medical staff at the Hospital.