Report Date


Case Against

Cardiff and Vale University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Ms Y complained on behalf of her late partner, Mr X, about the care and treatment he received from Cardiff and Vale University Health Board. In particular, Ms Y complained that the Health Board did not determine the cause of Mr X’s seizures in a reasonable and timely manner, that it unreasonably prescribed andadministered medication to him, that communication with Mr X and his family was poor, and that no assessment of capacity was completed with Mr X.

The investigation found that there was a significant delay in reporting the results of Mr X’sfirst MRI scan, which was compounded by a delay in anyone acting on the results of that scan, resulting in a 12 week wait. Thereafter a second “urgent” scan was requested, but there was a delay of 2 weeks before the request was even entered on to the request system, resulting in an 8 week wait. This was unacceptable and amounted to a service failure, as well as the uncertainty causing Mr X a significant injustice, therefore the complaint was upheld. In relation to medication, the investigation found that the prescription of medication to Mr X was in line with normal practice, however due to lack of contact for Mr X, he was not able to discuss his concerns about his medication. The investigation did not uphold this element of the complaint.

The investigation upheld Ms Y’s complaint that communication with Mr X and his family was poor, for the reason set out above, and because Mr X and Ms Y were told, incorrectly, that they would have outpatient appointments fairly quickly after Mr X’s discharge from hospital, when this was not the case. There were also concerns that Mr X was advised to contact his GP when specialist advice was required, there were significant delays in internal communication at the Health Board, and delays in complaint handling so that Mr X was not aware of the outcome of the complaint prior to his death, all of which caused him an injustice.

The complaint that Mr X did not receive a capacity assessment was not upheld as there was evidence that a detailed assessment was undertaken when Mr X was an in-patient, which was considered sufficient to record that Mr X did have capacity.

The Health Board had recruited neuro-radiologists to address the shortage of specialists before this report was concluded. The Health Board also agreed to provide a full apology to Ms Y, to consider undertaking audits of delays in typing and entering scan requests on to the MRI system, and for their process for communicating abnormal results to clinicians. It also agreed to consider inviting specialists from different teams to other services’ multi-disciplinary meetings in order to discuss patients with multiple health conditions.