Avoidable death of a patient in care of Cwm Taf Morgannwg University Health Board

The Ombudsman launched an investigation after receiving a complaint from Miss V about care and treatment provided to her cousin, Ms F, by Swansea Bay University Health Board and Cwm Taf Morgannwg University Health Board.  Miss V was concerned that the Health Boards missed opportunities to identify and treat Ms F’s appendicitis. Ms F died of sepsis induced by a ruptured appendix in August 2020.

The Ombudsman did not uphold the complaint against Swansea Bay UHB. She concluded that the evidence showed that it was unlikely that Ms F had appendicitis when she was under that Health Board’s care.

However, the Ombudsman did uphold the complaint against Cwm Taf Morgannwg UHB. She concluded that the Health Board had missed opportunities to identify and treat Ms F’s appendicitis during her two attendances at the Ambulatory Emergency Surgical Unit at Princess of Wales Hospital, Bridgend, on 17 and 20 July 2020.

The Ombudsman found that if Cwm Taf Morgannwg UHB had provided appropriate care on 17 or 20 July, Ms F’s appendicitis would have been identified and treated, and her death could have been avoided.

Commenting on the report, Public Services Ombudsman for Wales, Michelle Morris, said:

“This was a tragic case and our sympathy is extended to the family. We do not make the finding of avoidable death lightly, however, the injustice to Ms F and her family could not have been more serious.

Our investigation found no evidence that appendicitis was even considered as a potential diagnosis either on 17 or 20 July, and our clinical adviser in this case told us categorically that that approach was inadequate.

I am struck by the evidence from the family that Ms F did not return for review after 20 July because, based on her experience of the care provided up to that point by Cwm Taf Morgannwg UHB, she felt that that would have been of little benefit.

Our clinical adviser in this case told us that death from appendicitis was uncommon, but that death from undiagnosed appendicitis following discharge was even less common. Given this, we were concerned that the Health Board’s investigation of this case had not identified any learning points or recommendations, despite clear indications that the management was not sufficient on either 17 or 20 July. This, and the grave injustice to Ms F and her family left me with no choice but to issue a public interest report on this case.

I welcome that Cwm Taf Morgannwg UHB has now accepted these findings and conclusions and has agreed to implement the recommendations in full.”

The Ombudsman recommended that Cwm Taf Morgannwg UHB issues a fulsome apology to Miss V and the family, acknowledging that it missed opportunities to take steps which would likely have avoided Ms F’s death, and

• supports them to access independent legal advice to assess the contents and findings in the Ombudsman’s report, and ensures that they receive appropriate financial compensation for the significant injustice caused to them
• shares a copy of the Ombudsman’s report among the relevant staff and the Surgical Clinical Governance Team, ensuring that the failings identified in the report are reflected upon and improvement to practice are made
• reminds all clinicians working in ambulatory settings to be mindful when assessing patients with abdominal pain that a significant proportion of patients do not present with typical appendicitis
• carries out a review of practice and procedure to address the failings identified in the Ombudsman’s report, and produces an action plan to show how it will achieve improvements.

To read the full report, click here.