Report Date


Case Against

Cardiff and Vale University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Ms L complained that the Health Board failed to take appropriate safety measures in applying an alcoholic solution of chlorhexidine (a substance used to sterilise the skin) whilst cannulating her baby daughter, M (inserting a thin tube into the vein to administer medication or drain fluid) in preparation for surgery. Ms L also complained that staff failed to change the continence sheet despite M’s groin being sprayed with chlorhexidine on multiple occasions.

The Ombudsman upheld the complaint. The Ombudsman found it was very likely that M sustained burns through extended contact with chlorhexidine solution that had pooled on the continence sheet, and that appropriate safety measures were not taken, nor was the continence sheet changed as it should have been. The Ombudsman noted that the risks of skin damage from the use of chlorhexidine solutions were already known, and that a similar incident involving a baby had occurred within the Health Board 3years earlier. The Ombudsman noted that the solution had been applied using an unmetered spray, and that the Health Board should have considered the use of “prepsticks”,single use applicators with a sponge tip, as a safer alternative. The Ombudsman considered that the Health Board had failed to learn from the previous incident and national guidance, and that had it made changes to its procedures, the likelihood of M suffering burns could have been reduced. The Ombudsman also found that the Health Board’s response lacked openness and did not acknowledge that pooling was known to be a risk with the use of chlorhexidine solutions, or that a similar incident had previously occurred.

The Ombudsman recommended that within a month of the report, the Health Board apologise to Ms L and pay her a total of £1500 in recognition of the pain suffered by M, the distress, disruption and anxiety caused to her parents and the Health Board’s poor handling of her complaint. The Ombudsman further recommended that within 3 months of the report, the Health Board should review its procedures to ensure that prepsticks were used where clinically appropriate, and provide evidence that it had done so.