Report Date


Case Against

Cwm Taf Morgannwg University Health Board



Case Reference Number



Upheld in whole or in part

Mrs A complained to the Ombudsman that when her mother, Mrs B was admitted to the Emergency Department (“the ED”) of the Princess of Wales Hospital (“the Hospital”), they had failed to assess and investigate her symptoms which were indicative of a stroke sufficiently quickly. She considered that this failure impacted on the treatment options that would otherwise have been available, including surgery, to address the bleed on her brain that was subsequently identified. Mrs A also complained that her mother contracted Covid-19 during her subsequent admission to the hospital.

The Ombudsman found there had been an inappropriate delay between Mrs B’s triage and the time at which she was assessed by an ED doctor even taking into account the impact that the COVID-19 pandemic had on the delivery of NHS services. Mrs B should have been rapidly assessed using the Rosier score, but this did not happen in a timely manner. This amounted to a service failure by the Health Board. However, the Ombudsman found no persuasive evidence that the delay would have altered the sad outcome for Mrs B. The Ombudsman did however uphold the complaint to the limited extent that this failing would have led to an uncertainty for Mrs A that the outcome would have been different. The complaint about Mrs B contracting COVID-19 following her admission to the Hospital was not upheld because it was concluded that on balance it was more likely that Mrs B contracted the virus prior to her admission to the Hospital.

The Ombudsman recommended that the Health Board provide Mrs A with an apology for the failings identified in the report. She also recommended that the Health Board ensured that the failings identified in the report be used for reflective learning with the clinical staff involved in Mrs B’s care. Finally, the Ombudsman recommended that the

Health Board should issue a reminder of the stroke pathway to all locum and trainee doctors upon commencing their service within the Health Board.