Report Date


Case Against

Torfaen County Borough Council


Services for older people

Case Reference Number



Upheld in whole or in part

Ms A complained about a GP Practice (“the Practice”) in the Aneurin Bevan University Health Board (“the Health Board”) area who provided care and treatment to her father, Mr B, while he was a resident at a care home (“the Care Home”). His residency at the Care Home was funded by Torfaen County Borough Council (“the Council”). Specifically, Ms A complained that:

• The Practice failed to provide timely and appropriate care and treatment to Mr B between January and May 2019, when Mr B had a below the knee amputation.
• The Care Home failed to provide timely care and treatment to Mr B in terms of pressure area management and wound management, failed to communicate with, and involve her, in decision making including failing to allow her to view Mr B’s foot, and failed to act upon concerns raised by Ms A.
• The Council failed to review/monitor Mr B’s care while he was a resident at the Care Home.
The investigation found that the care provided by the Practice was appropriate with timely and appropriate investigations conducted, that test results were reviewed in a timely manner and actioned appropriately, and it was appropriate not to refer Mr B to hospital before 13 May. As such, the complaint against the Practice was not upheld.

The investigation found that the Care Home acted in a timely manner by seeking assistance from the District Nurse (“DN”) Team when Mr B’s heel wound was first noticed and acted promptly in seeking GP input when an infection was suspected. The investigation found that Mr B did not initially want his information shared with Ms A without his consent, and, therefore, it would not have been appropriate to share and involve Ms A in decision making regarding his health, care and treatment. The investigation found that the Care Home did not fail to act upon concerns raised by Ms A about Mr B’s foot. As such, these aspects of the complaint were not upheld.

However, Mr B was not subject to a prompt and thorough skin assessment by Care Home staff when he was first admitted. To this limited extent, this aspect of the complaint was upheld. However, the Care Home did refer Mr B to the DN Team the following day. The Ombudsman was satisfied that the Care Home has taken appropriate remedial action by introducing full skin assessments for all new residents and regular assessments for all existing residents. He did not consider there was any further remedial action that could achieve anything further. The investigation was unable to reach a finding in relation to whether Ms A was permitted to view Mr B’s foot.

The investigation found that, due to the lack of comprehensive record keeping by the Council, it was not possible to determine whether the Council appropriately reviewed/monitored Mr B. The uncertainty caused by this failing was an injustice to Ms A and the complaint was upheld. The investigation also found that the Council failed to provide guidance to the Care Home on what information could be shared with Ms A after Mr B was deemed to lack capacity. This led to confusion and frustration on Ms A’s part. This was an injustice to Ms A and this aspect of the complaint was upheld.

The Council agreed to provide Ms A with a written apology, make a payment of £500 to Ms A for the uncertainty caused by the lack of records and in acknowledgement of the confusion, frustration and distress caused by the failure to fully and clearly communicate to the Care Home how and what information could be shared with Ms A. The Council also agreed to share the report with the relevant Social Worker for reflection and to improve future performance.