A cancer patient died without suitable end-of-life care following surgery, an Ombudsman investigation has revealed.

Mrs W (anonymised) complained about the care provided to her husband, Mr W, (anonymised) by Abertawe Bro Morgannwg University Health Board, following his oesophageal (relating to the food pipe between the throat and stomach) cancer surgery in February 2018.

Mrs W said that Mr W never really recovered after his surgery; he struggled to eat and became emaciated, immobile, incontinent and depressed. Although palliative support was eventually arranged, this was only arranged just two weeks before Mr W died in September 2018.

Consequently, relevant palliative care aids, such as a commode and a hospital bed, were still in the process of being delivered and installed and Mr W never had the benefit of them.

Mrs W said that witnessing her husband’s slow deterioration and death as his sole carer and without advice or support left her with feelings of pure terror and helplessness that would stay with her forever. She said could not understand why Mr W was not given the help and support that he needed and deserved.

The Ombudsman found that there were communication failures around explaining diagnosis, prognosis and likely outcomes to the patient and provide providing psychosocial support and specialist dietetic support before, during and after his surgery.

The Ombudsman concluded that there was no evidence that the Health Board provided adequate and appropriate palliative post-discharge care and support to the patient and his family following his unsuccessful surgery and failed to deal with the requests from the patient’s family for contact and support promptly.

Swansea Bay and Cwm Taf Morgannwg Health Boards, have agreed to a number of recommendations including a written apology for Mrs W and to implement compulsory training for all doctors and nurses treating and managing patients with gastro-intestinal cancer, covering advanced communication skills and the need for patient involvement in care.

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

“This is a deeply shocking case where a man has died without suitable end-of-life care, and sadly, I think that both Mr and Mrs W’s human rights are likely to have been compromised.

“Mr and Mrs W were not given the time to prepare for his eventual outcome, both mentally and with suitable palliative care aids and support. This impacted on Mr W’s rights as an individual, and on both his and Mrs W’s rights as part of wider family life.

“This is particularly important at the end of someone’s life and the failures identified therefore represent serious injustices to both Mr and Mrs W.

“The lack of support given to Mrs W has left her with unimaginable emotional pain and I can only hope my investigation brings her some small comfort.”


For further information please contact Matt Aplin, Head of Communications and Public Affairs, at communications@ombudsman.wales or call 07957 440846.

To read the report, click here.