Report Date


Case Against

Cardiff and Vale University Health Board



Case Reference Number



Voluntary settlement

Mr B complained that the Health Board had not appropriately considered his family member’s case as part of its nosocomial review process. In particular, Mr B considered that his family member was placed on a “covid ward” and this was not addressed in the Health Board’s decision letter.

The investigation found that the decision letter contained insufficiently detailed reasons for the Health Board’s conclusion that there was no qualifying liability of harm to Mr B’s family member. The decision letter also did not address whether there was an opportunity for Mr B’s family member to have been discharged sooner and whether that would have affected the outcome. This caused injustice to Mr B as the Health Board had not provided sufficient information to explain how it had reached its decision.

The Ombudsman sought and gained the Health Board’s agreement to carry out a fresh, thorough, nosocomial review, to include consideration of nosocomial, duty of care and qualifying liability issues. The need to address the discharge planning issues and COVID-19 status of the ward in its response was highlighted. The Health Board agreed to write to Mr B with a fulsome explanation of the reasons for its decision and provide a copy to this office within 6 weeks.