It was found that the woman’s catheter bag was not emptied regularly, there was a delay in her receiving a pressure mattress and the syringe driver was not checked every four hours when it should have been.The health board has been urged to apologise to Mr C as well as make sure that checks on syringe drivers are carried out every four hours, that X-rays should be reported without undue delay and that consideration should be given to administering IV fluids and IV antibiotics to patients who