The Public Services Ombudsman's report into the death of a dementia sufferer four months after he was admitted to a hospital in Swansea has found a 'pattern of failures.'
Abertawe Bro Morgannwg University Health Board has apologised and says major changes have taken place at Cefn Coed Hospital since then.
The Healthcare Inspectorate Wales says it's now considering strengthening its risk assessment and inspection process.
Here's our Health Reporter Rob Osborne.
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