Report Date


Case Against

Cardiff and Vale University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Mrs A complained to the Ombudsman about the care given to her late father, Mr B, by Cardiff and Vale University Health Board. As a result of a previous stroke, Mr B was being treated with an anticoagulant to prevent the formation of blood clots which could lead to a stroke. Because Mr B needed to have surgery to address issues of rectal bleeding, his anticoagulant was suspended. On the day following his surgery, whilst recovering on the ward, he was noted to be confused and disorientated. Nursing staff called a doctor who saw Mr B at 13:00 and concluded that while Mr B had no evidence of any neurological problems he should not be sent home, and arranged a chest X-ray and other tests. The same doctor reviewed Mr B nearly 5 hours later, and arranged a CT scan of his head as Mr B appeared confused, which at approximately 19:00 indicated that Mr B had experienced a stroke. A review by another doctor at approximately 21:00 concluded that it was too late for clot-busting therapy although anti-platelet therapy (to stop cells in the blood from sticking together to form further clots) was arranged. Mr B’s condition deteriorated further and sadly he died in hospital. Mrs A also complained about the manner in which the Health Board dealt with her subsequent complaint.

The Ombudsman found that the diagnosis of Mr B’s stroke was unreasonably delayed. He was already at a heightened risk of having a stroke as a result of the suspension of his medication, (which could have reduced that risk), there had been a sudden and significant change in his condition and early stroke diagnosis is crucial for treatment purposes.

The Ombudsman also found that the Health Board took too long to consider Mr B’s treatment options and to start his stroke-related treatment.

The Ombudsman also found the Health Board’s failure to identify its shortcomings when responding to the family’s concerns demonstrated that it did not investigate their concerns properly, leading to additional distress.

The Ombudsman upheld both elements of Mrs A’s complaint about Mr B’s clinical treatment – that there had been delays in diagnosing and treating Mr B’s stroke. She also upheld Mrs A’s complaint about failures with the complaint handling process. It was recommended that the Health Board apologise to Mrs A and provide her with redress of £1000 for the distress and uncertainty stemming from the clinical failings identified and £500 redress for the additional distress caused by its inadequate complaint response.

The Ombudsman also recommended further action to be taken by the Health Board including that the clinician who assessed Mr B discuss the event at his next review with his supervisor.

It was also recommended that the report be shared with other staff.