A complaint was made by the sister of Mr Y (anonymised) about the care and treatment provided to the 55-year-old at Prince Charles Hospital, Merthyr, in April 2015.

The sister, referred to as Ms X, approached the Ombudsman after Cwm Taf University Health Board failed to address her concerns.

Mr Y attended the hospital with severe abdominal pains, was discharged but readmitted within days after being found confused and suffering from hypothermia.

The Ombudsman found the following failings:

•           Sepsis should have been recognised and treated earlier.

•           Steroid psychosis,  which caused Mr Y’s confusion, was not identified promptly causing additional worry for Mr Y and his family.

•           Recognition that Mr Y was experiencing a flare up of severe colitis was slow and there was an unnecessary delay in re-referral to appropriate specialists

•           Opportunities were missed to recognise the seriousness of Mr Y’s condition.

•           There was a delay in Mr Y starting on new medication, and that there was no adequate multi-disciplinary review or explicit review of his abdominal X-ray.

Commenting on the report, Nick Bennett, Public Services Ombudsman for Wales, said:

“My investigation has highlighted a catalogue of serious failings with regards to the care and treatment of Mr Y and sadly we will never know if the outcome would’ve been different had he been treated in the correct manner with surgery taking place sooner.

“This is a tragic injustice for Ms X and I can only hope my investigation brings her some kind of closure.

“I am also concerned that the Health Board did not identify failings earlier when the complaint was originally made.

“A Consultant Surgeon reviewed the medical notes only after my investigation was commenced. This type of poor complaint handling was highlighted in my recent thematic report Ending Groundhog Day, and only adds to the distress to the family during a period of grieving.”

Cwm Taf University Health Board has agreed to all of the Ombudsman’s recommendations including paying Ms X £4,500 for the shortcomings and injustice caused to Mr Y and Ms X.