Report Date


Case Against

Cwm Taf Morgannwg University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Miss A complained about a number of aspects of the standard of care provided to Mr T by Cwm Taf University Health Board between January and May 2019 during admissions to Prince Charles Hospital and Ysbyty Cwm Cynon, following surgery. The Ombudsman investigated Miss A’s complaints, which included concerns about:

• post surgical district nursing care
• food and fluid intake, malnutrition and weight loss management
• diabetes management and monitoring
• stoma care
• wound care
• recognition of infection and sepsis, and infection control
• reduced renal function
• low haemoglobin levels
• arrangements for post discharge care and follow up appointments
• complaint handling

What we found
The Ombudsman upheld aspects of the complaint.
The complaints relating to the district nursing care, and the delayed response to the complaint were upheld. During Mr T’s inpatient stay, there were identified shortcomings in fluid balance recording, and in the care and management of Mr T’s stoma by nursing staff. These aspects of the complaint were also upheld. The Ombudsman found no shortcomings in relation to the monitoring of Mr T’s diabetes, nutritional status, infection or wound care. The Ombudsman did not uphold the complaints relating to the medical treatment of his infection, his renal function or diabetes.

The Ombudsman made recommendations in relation to the provision of stoma care, fluid balance monitoring and training for nursing staff.