Report Date


Case Against

Cwm Taf Morgannwg University Health Board



Case Reference Number



Upheld in whole or in part

Mr A complained that during January and February 2021 the Practice failed to provide appropriate care and treatment to his father, Mr B, after he tested positive for COVID-19. Sadly, Mr B died in hospital on 13 February.

The Ombudsman found that the Practice failed to carry out an appropriate assessment of Mr B’s condition during a telephone consultation on 3 February and failed to arrange a timely face to face assessment on 11 February. These were service failures which denied Mr B the opportunity to receive appropriate treatment sooner. The Ombudsman found that, on the balance of probabilities, Mr B would have died even if he had received treatment for the COVID-19 infection on or around 3 February. However, the lost opportunity for a better outcome and the resulting distress and uncertainty over what might have been, were significant injustices to Mr A and his family. For these reasons, the Ombudsman upheld the complaint.

The Ombudsman recommended that the Practice should:
• Apologise to Mr B for the failings identified.
• Make a payment of £500 to him in respect of distress arising from the missed opportunities to arrange earlier supportive care for Mr B.
• Share the report with the GPs involved and remind all of its GPs of the importance of good record keeping.
• Discuss the report at a Clinical Governance Meeting and agree an action plan to improve the way it carried out remote consultations.

The Practice agreed to the recommendations.