Clinical treatment in hospital : Cardiff and Vale University Health Board

Miss A complained about several issues relating to the care provided to her late mother before her death, including whether she was adequately monitored, whether her observations/presentations were normal and whether her care was escalated appropriately. She also complained that her mother’s medical records relating to the admission were missing.

In the absence of the relevant medical records the Ombudsman was unable to consider the adequacy of the clinical care provided. This represented a significant injustice to Miss A and her family.

The Ombudsman contacted the Health Board and in resolution of Miss A’s complaint it agreed that within 20 working days it would provide Miss A with a meanful apology for the loss of records, make a redress payment of £1,500 for the lost opportunity to have her complaint considered, to continue searching for the records and tore-iterate the offer of a meeting with the family.