Report Date


Case Against

A GP Practice in the area of Cardiff & Vale University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Miss A complained about the care and treatment provided for her late sister, Miss B, by the GPs and staff at the Surgery. Miss A said that the Surgery failed to refer Miss B for urgent investigations for suspected endometrial cancer (cancer of the womb lining) and to provide appropriate treatment and support during her illness. Miss A also said that the Surgery failed to verify Miss B’s date of death before completing her death certificate which was wrong and had to be altered. Finally, Miss A raised concerns about the Surgery’s handling of a complaint made by Miss B before she died.

The investigation found that Miss B’s care and treatment had generally been appropriate. Miss B’s age, menstrual history and presentation along with normal investigation findings gave rise to a low suspicion for endometrial cancer and urgent investigations were not indicated. The Surgery had established Miss B’s date of death from information provided by Miss A and later altered the date on the original death certificate at her request. Although there was no requirement for the Surgery to do more to verify the date of death, it was invited to reflect on what had happened in view of the subsequent delay and distress that was caused to Miss A. These aspects of the complaint were not upheld.

The Surgery said it had prepared a written response to Miss B’s complaint but had decided not to send it as she was about to start cancer treatment. However, the records showed that the Surgery’s complaint investigation was incomplete. Consequently, the Surgery had missed the opportunity to identify any learning and improvement from the complaint and to reassure Miss B about her ongoing care. The complaint was upheld and the Ombudsman recommended that the Surgery should apologise to Miss A for failing to respond to her sister’s concerns.