Source · PSOW (Public Services Ombudsman for Wales)

Cwm Taf Morgannwg University Health Board

PSOW (Public Services Ombudsman for Wales) Upheld Reference PSOW-202005302 Sector Health Category Clinical treatment in hospital Decided 07 February 2022

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Full decision

Mrs A complained about the appropriateness of the discharge arrangements following her mother-in-law (Mrs B’s) admission to hospital.

The investigation found that Mrs B did not meet the medical criteria for discharge as set by the Consultant and that a stairs assessment should have been undertaken prior to discharge. It also found that whilst Mrs B said her daughter would move in to help/assist following discharge, direct contact was not made with Mrs B’s family to clarify this arrangement or to give them the opportunity to ask questions about discharge. These complaints were upheld. The investigation found there was no requirement for an Occupational Therapy referral to have been made and that a repeat COVID-19 test was not necessary prior to discharge. Given the lack of documentary evidence it was not possible to determine if discussions were held with Mrs B around a package of support/care, however there was no clinical indication that any adaptions/equipment was required. These complaints were not upheld.

Whilst it was not a specific head of complaint, overall the investigation identified that the quality of record keeping by nurses on the ward was not in line with relevant guidance. The Health Board agreed to implement improvement action in this regard.The Health Board also agreed to: • Provide Mrs A with an apology.

• Disseminate a circular to nursing staff to review relevant nursing guidance and to clinical staff to review guidance on how to calculate and accurately complete National Early Warning Score charts.

• Try to identify specific members of staff identified as not complying with record keeping standards, provide them with a copy of the report and ask them to reflect on their individual failures.

• Invite a member of the clinical staff to reflect on the report and discuss the findings at their next annual appraisal.

• Outline how it proposes to provide more effective communication with patients’ families around discharge planning (especially during a period whereby visiting is restricted) and how progress in this area will be monitored.

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Other decisions involving Cwm Taf Morgannwg University Health Boa…

Reference Date Summary Outcome
PSOW-202511046 29 Apr 2026 Mrs A complained that Cwm Taf Morgannwg University Health Board failed to respond to her complaint. The Ombudsman found that … Resolved / Early Resolution
PSOW-202510579 28 Apr 2026 Ms B complained that the Cwm Taf Morgannwg Health Board failed to respond to the concerns she raised in her … Resolved / Early Resolution
PSOW-202509919 27 Apr 2026 Miss B complained that Cwm Taf Morgannwg University Health Board failed to send its complaint response to her Social Worker. … Resolved / Early Resolution
PSOW-202510338 27 Apr 2026 Miss A complained that Cwm Taf Morgannwg University Health Board had not fully addressed her complaint about care and treatment … Resolved / Early Resolution
PSOW-202501014 24 Apr 2026 Mr C complained about the care and treatment he received from Cwm Taf Morgannwg University Health Board. Specifically, the investigation … Not Upheld
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