'We've seen a number of cases where people at the end of their life have not been cared for properly," says Public Services Ombudsman Peter Tyndall.
"I think there are instances where cultural change will be called for. In many cases there is excellent care being provided, but there are still isolated cases of this kind that need to be tackled."
The distress of the family in losing a loved one is a matter of great concern. I think for them this is something that will always remain with them and it does again stress the importance you have to look after people at the end of their lives well.
"I am confident that the changes can be made and will be made, but I think it requires sustained management attention to make sure that we don't slip away from the standards that need to be sustained."
More top news
Green keeper Gareth Pugh died after he fell into a lake while collecting golf balls.
The Newsweek Quiz - where we will be testing your knowledge from the last seven days of news here in Wales.
Swansea must learn the Italian art of defending to continue their climb up the league table, says head coach Francesco Guidolin.