Report Date


Case Against

Aneurin Bevan University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Mr X complained about the gastroenterology care and treatment he received by the Health Board. The investigation considered whether there was a failure to diagnose Mr X with Coeliac Disease (a condition where the immune system attacks the body’s tissues when gluten is eaten which damages the small intestine so that the body is unable to take in nutrients) in a timely and appropriate manner.

The Ombudsman found that as Mr X (who has type 1 diabetes) was presenting with new onset bowel symptoms, and that Coeliac Disease is a well-known association of type 1 diabetes, that it should have been considered as a possible cause of Mr X’s symptoms. She found that consideration should have been given to carrying out a tTG test (used for screening and detecting Coeliac Disease) and that this would have been in line with the requirements of relevant guidance on the diagnosis of Coeliac Disease. Mr X was not tested and this was a service failure and contrary to the requirements of relevant guidance which caused Mr X an injustice as it delayed the diagnosis of the cause of his bowel symptoms. The Ombudsman upheld Mr X’s complaint.

The Health Board agreed to implement the Ombudsman’s recommendations to apologise to Mr X, to make a financial redress payment for the distress caused by the delay, to share the report for learning with relevant clinicians and to review relevant pre-assessment documentation to consider including further information to identify appropriate tests.