Report Date


Case Against

Cwm Taf Morgannwg University Health Board



Case Reference Number



Upheld in whole or in part

Mrs F complained that, while her husband Mr F was admitted to hospital in July 2020, Cwm Taf Morgannwg University Health Board (“the Health Board”) completed a Do Not Attempt Cardiopulmonary Resuscitation (“DNACPR”) form inappropriately.

The investigation found that the records did not show that the extent to which Mr F’s existing conditions impacted on the likelihood of successful resuscitation and Mr F’s wishes were appropriately considered. It found that poor record keeping illustrated a failure to follow the DNACPR policy which amounted to maladministration. The absence of appropriate records and appropriate clinical authority to support the decision called into question whether the DNACPR decision should have been made at all. The investigation found that there was also a failure to include Mrs F in the discussion and a failure to inform her of the decision. Whilst there was no clinical impact as a result of the DNACPR decision, the lack of communication and the failure to provide adequate evidence to demonstrate that the decision was appropriate caused Mr and Mrs F considerable distress which was an injustice to them.

Following Mrs F’s complaint to the Health Board, it took appropriate action to put things right in that it made sure that Mr F’s records clearly indicated that Mrs F should be included in discussions and decisions about her husband’s care. Additionally, the DNACPR form was rescinded, removed from Mr F’s records and provided to Mrs F for destruction.

The Health Board further agreed to provide a written apology to Mr and Mrs F, remind all staff of the importance of following the DNACPR policy, and ensure that the Doctor reflected on the findings of the investigation.