The Ombudsman launched an investigation after receiving a complaint from Mr D about the care and treatment received at the University Hospital of Wales during a scheduled admission for surgery to remove the right side of the colon.

Mr D complained that his condition was not clearly diagnosed and that clinicians were slow to identify that he suffered a post-operative bleed and required further emergency surgery.  Mr D also complained that information about his treatment and care was not conveyed clearly to him despite his Asperger’s Syndrome.  Finally, he complained about aspects of his care following his discharge from hospital.

The Ombudsman found that Mr D’s surgery was conducted on the presumption that Mr D had Crohn’s Disease.  However, surgical findings later suggested complex chronic appendicitis.  Neither condition required the extensive surgery that Mr D underwent.  The Ombudsman also concluded that there was no complete record of how Mr D’s condition was monitored following his surgery and that his post-operative bleed might have been detected sooner. In addition, although clinicians were aware of Mr D’s Asperger’s Syndrome, they did not clearly communicate the information about his diagnosis and treatment to him.  Finally, the Ombudsman found that although Mr D requested to be seen by a mental health clinician, this was not arranged.  However, the Ombudsman did not uphold Mr D’s complaint regarding his care post-discharge.

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

‘This regrettable case highlights yet again the importance of one of the key principles of prudent healthcare formulated by the Welsh Government – ‘do only what is needed, and do no harm’.  Physicians responsible for Mr D’s care should have employed a ‘watch and wait’ approach in which his condition would probably have settled without surgical treatment.  Instead, Mr D, a vulnerable individual, faced completely avoidable trauma of unnecessary surgery and post-treatment complications – a trauma which saw him seek mental health support.  I anticipate that my findings will be extremely distressing for him.  This is reflected in my recommendations in this case.’

The Ombudsman recommended that Cardiff and Vale University Health Board provides Mr D with a detailed apology and a redress payment of £10,000.  He also recommended that physicians and nurses involved in Mr D’s care undergo relevant training in the management of Crohn’s Disease and chronic appendicitis as well as in the care and management of patients with Asperger’s Syndrome.  The Ombudsman additionally recommended that the nursing team consider the importance of conducting and documenting post-operative observations and of preparing accurate and relevant care plans.

Cardiff and Vale University Health Board has accepted the findings and conclusions of the Ombudsman’s report and has agreed to implement his recommendations.

To read the report, click here.