Report Date


Case Against

Velindre University NHS Trust


Clinical treatment in hospital

Case Reference Number



Not Upheld

Ms A’s complaint related to the care and treatment that her late partner, Mr B, received from the Health Board and the Trust in 2020. Specifically, Ms A complained that there had been a delay in the Health Board confirming her partner’s diagnosis of lung cancer with a biopsy, and that both the Health Board and the Trust then failed to start his treatment immediately after this diagnosis was confirmed in September 2020. Following Mr B’s admission to hospital in October 2020, Ms A complained that a Do Not Attempt Cardiopulmonary Resuscitation (“DNACPR”) form was inappropriately placed on her partner’s records and that the Health Board failed to provide him with appropriate care and treatment during the admission. Furthermore, Ms A raised concerns that she was denied the opportunity to visit Mr B before he died, despite being informed that he was “critically ill” and numerous family members then being allowed onto the ward after his death, and that the Health Board failed to provide her with regular updates on Mr B’s condition and did not contact her to inform her of his death. In addition, Ms A also raised concerns that her partner’s basic hygiene needs were ignored given that he died in the same clothes that he was admitted to hospital in 2 days beforehand. Ms A also complained about the accuracy and completeness of the Health Board’s complaint response.

The Ombudsman concluded that although there were delays in confirming Mr B’s diagnosis with a biopsy, these delays were not due to any identifiable failings on the part of the Health Board and appropriate investigations into Mr B’s lung cancer had been undertaken in accordance with relevant guidelines. The Ombudsman also considered that the length of time between the confirmation of Mr B’s diagnosis and the proposed start date for treatment had been reasonable under the circumstances. As a result, the Ombudsman did not uphold these complaints. In terms of Mr B’s later admission to the Hospital, the investigation found that, although there were some shortcomings that had already been identified by the Health Board, the decision surrounding DNACPR had been clinically justified and this decision had been discussed with Mr B at the time. The investigation also found that Mr B had received appropriate medical care and treatment during his admission to the Hospital and that the decision to not transfer him to the ICU was reasonable. In addition, the Ombudsman could not conclude that Ms A’s complaint that her partner was wearing the same clothes on the day he died as when he was admitted 2 days earlier was necessarily due to any failings on the part of the Health Board. Therefore, the Ombudsman also did not uphold these complaints.

However, the Ombudsman considered that there were shortfalls in the communication with Ms A during her partner’s admission and that it should have been recognised after Mr B deteriorated further in the latter part of the admission that he was likely to die within a matter of days, which could have then triggered considerations about Ms A being allowed to visit him before he died. As a result, the Ombudsman upheld these complaints. In addition, the Ombudsman also upheld Ms A’s complaint about complaint handling.

As a result of these findings, the Ombudsman recommended that the Health Board made a meaningful apology to Ms A and that the investigation report was shared with the relevant staff and the ward to reflect on its findings and the importance of timely and proactive communication with families, especially for patients who are in the last days of life.