A report by the Public Services Ombudsman for Wales has found that the care received by a 20-year-old woman born with Severe Development Delay, failed to recognised her individual needs. The report found that the woman, known only as Sarah, faced unacceptable delays in administering medication she needed when she was admitted to an adult hospital ward at the Royal Glamorgan Hospital. Her mother (Mrs A) complained to the ombudsman about Sarah's treatment and care she received at the hospital upon her transition from child to adult hospital care.

During Sarah's only admission to an adult hospital ward, there were unacceptable delays in administering the appropriate antibiotic medication and that staff were not trained or equipped to meet Sarah's needs because of a lack of co-ordination between services during the transfer of her care.

Sarah died in hospital on 21 October 2009, aged 20. Her mother believes that the outcome of her final hospital admission would have been different had Sarah's treatment and care been satisfactory.

The Ombudsman found that arrangements for Sarah's transfer of hospital care were inadequate.

There was no evidence either of a clear, co-ordinated transfer process or of an effective hand over of care. The health board also failed to plan and deliver services in a way that recognised Sarah's individual needs in accordance with the equalities legislation.

The Ombudsman also found that aspects of Sarah's clinical treatment fell below a reasonable standard. There was a failure to initiate treatment with intravenous antibiotics within four hours of Sarah's admission to hospital and also a further delay of more than 21 hours during which two doses of prescribed oral antibiotics were not given.

The Ombudsman didn't say whether or not the outcome would have been different for Sarah because of those clinical failings. Finally, the investigation identified that there were inadequacies in the health board's handling of Mrs A's complaint.

The Ombudsman upheld each element of Mrs A's complaint, and made a number of recommendations to the health board for further action to address the failings identified.

The health board agreed to implement the recommendations and to apologise and make a redress payment to Mrs A of £2,000 in recognition of the problems with her daughter's care, and the resulting uncertainty over the sad outcome.