Health Minister Mark Drakeford has ordered an independent inquiry into one of the biggest health boards in Wales.
The Minister has acted after the death of grandmother Lilian Williams.
Abertawe Bro Morgannwg had apologised for what her family say was appalling care and the fact that the promise of a high level investigation into it in 2010 never happened.
Tonight ITV News can reveal new information which her family says goes to the top of the Welsh NHS.
Our Health Reporter Rob Osborne reports.