Death of patient in care of Cardiff and Vale University Health Board after “significant service failure”

The Ombudsman launched an investigation after Miss X complained about the care and treatment that her late father, received at University Hospital of Wales in March 2020.  Her father, Mr Y, went to the Emergency Department with symptoms of obstructed hernia* and bowel obstruction**. However, he was discharged without being adequately assessed. Two days later, he was admitted to the Hospital, but sadly died a few days later after emergency surgery.

The Ombudsman found that when Mr Y was first admitted the Health Board did not adequately consider his clinical history and new symptoms. All these symptoms pointed to an acute obstructed hernia which needed treatment – yet the patient was discharged. When he was admitted to hospital two days later, his condition was not promptly diagnosed, which led to a delay in an emergency surgery. Also, although he was very unwell following the surgery, he was not moved to the Intensive Care Unit, which could have increased his chances of survival. Had these failings not occurred, the outcome might have been different.

The Ombudsman took account of the impact of the COVID-19 pandemic had on the Health Board’s ability to deliver care and treatment.  However, she decided that the shortcomings in the care that the patient received from the Health Board amounted to a serious service failure, resulting in grave injustice for him and his family.

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

“Mr Y was admitted to hospital at the beginning of the COVID-19 pandemic, during a profoundly difficult time for the Health Board and its staff. However, he was an emergency case and did not receive the standard of care he should have.”

“I am saddened to conclude that, had these clinical failings not occurred and had the patient received appropriate care following surgery, his deterioration and death, on balance, might have been prevented.” 

“When complaining to us, Miss X told us that the family’s lives had been destroyed and they still did not have answers. I have no doubt that the findings of this report will be a source of great distress to her and her family.”

“I am pleased that the Health Board has accepted my recommendations in full.”

The Ombudsman recommended that Cardiff and Vale University Health Board should provide a written apology to Miss X for the failings identified in her report.

In addition, the Ombudsman recommended that the Health Board should:

• review with relevant staff how hernias are assessed and diagnosed and produce an action plan based on the outcomes of that review and share it with the Ombudsman and any clinical department for which the findings may be relevant.
• share the Ombudsman’s report with the Clinical Director responsible for the relevant clinicians involved in Mr Y’s care, and make sure that they reflect upon and directly discuss its findings.

*A hernia happens when an internal part of the body pushes through a weakness in the muscle or surrounding tissue wall.  An inguinal hernia is the most common type of hernia and can appear as a swelling or lump in the groin, or as an enlarged scrotum (the pouch containing the testicles).  The swelling may be painful.

**A bowel obstruction is a condition in which the bowels cannot work properly due to a narrowing of the bowel

To read the report, click here.