Report Date


Case Against

Cwm Taf Morgannwg University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Ms D complained about the care and treatment received by her late mother, Mrs E, from Cwm Taf Morgannwg University Health Board. Specifically, she complained about whether the treatment provided to Mrs E for cor pulmonale and fluid overload was clinically appropriate, if Mrs E should have been treated with antibiotics sooner than she was and if Mrs E was inappropriately left in soiled clothing.

The investigation found that whilst the plan developed to treat Mrs E for cor pulmonale and fluid overload was appropriate, the way that plan was put into action was not. Accurate records were not always kept, and necessary tests were not consistently carried out. Opportunities were missed to identify the seriousness of Mrs E’s condition and take appropriate action. As such these parts of Ms D’s complaint were upheld. The investigation found that Mrs E was prescribed antibiotics at the appropriate time, so this part of Ms D’s complaint was not upheld. There was evidence of Mrs E’s personal hygiene needs being met during her time in the Hospital but there was also evidence of potentially missed opportunities to better address her continence needs. This part of Ms D’s complaint was upheld.

The Health Board agreed to apologise to Ms D for the failings identified during the investigation. It also agreed to ensure that the clinicians that treated Mrs E were familiar with Acute Kidney Injury and its management and to remind all nursing staff involved in Mrs E’s care of the importance ensuring patients’ continence needs are regularly assessed and of completing charts clearly and accurately. The Health Board also agreed to review its procedure on the prescription of sedatives to frail patients, develop a procedure to ensure seriously ill patients are directly reviewed by a doctor at weekends and to develop a fluid balance and hydration protocol.