Report Date


Case Against

Aneurin Bevan University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

On 25 April 2019 Mr X’s GP referred him on an urgent suspected cancer (USC) basis for an enlarging lump on his buttocks. On 6 June the GP wrote that Mr X still awaited an appointment despite a USC referral. The same day, Mr X saw the Consultant Colorectal Surgeon and was referred for an MRI scan that subsequently reported a suspicious ill-defined mass within tissues of the left buttock. On 16 July a biopsy diagnosed sarcoma, which was later confirmed. Mr X was referred to another hospital and on 26 September underwent surgery. Sadly Mr X died on 2 February 2020 from metastatic cancer. Mrs X complained about whether the treatment Mr X received at Nevill Hall Hospital was timely and reasonable.

The Ombudsman found that Mr X’s USC referral was not prioritised for 17 days; the interpretation and assessment of the GP’s referral was not as expected of an enlarging lump on the USC pathway; Mr X should have been routed to the correct speciality; on 6 June Mr X could have been referred to the appropriate service when booking the MRI scan but was not; a delay in arranging a biopsy before 16 July when it could have been taken in the clinic or concurrently with the MRI scan on 20 June, and that there was a serious breach of the 62-day cancer standards referral to treatment (RTT). He found that the delay did not have a significant effect on Mr X’s treatment or prognosis. The Ombudsman upheld the complaint.

The Health Board agreed to implement the Ombudsman’s recommendations within 1 month and apologise to Mrs X for the identified failings. The Health Board agreed within 3 months to review the USC pathways to ensure improvements are made to minimise avoidable delays, and to report its findings and steps taken to improve the 62-day USC RTT standards to the Ombudsman.