Report Date


Case Against

Cardiff and Vale University Health Board


Clinical treatment in hospital

Case Reference Number



Voluntary settlement

Mr B complained about the care and treatment he received when he attended the Emergency Department (“the ED”) at the University Hospital of Wales on 17 April 2022. Mr B complained that he was not appropriately assessed, appropriate scans were not undertaken, and he was discharged prematurely. He also complained that the complaint response he received from the Health Board was factually incorrect.

Following commencement of the Ombudsman’s investigation, the Health Board reviewed Mr B’s care and its initial complaint response. It said, on review, the care provided to Mr B fell below a reasonable standard. It agreed to, within 4 weeks, apologise to Mr B and issue an updated complaint response, make a payment to Mr B of £1000 for the time and trouble in pursing this complaint, consider the case under its redress scheme with regard to a settlement for the additional pain and suffering experienced by Mr B due to the delay in a scan being undertaken, and share with the Ombudsman its updated guidance for investigation of Cauda Equina Syndrome (“CES”). It also agreed to, within 8 weeks, implement an additional clinical review process for all concerns regarding suspected CES injury, arrange for reviewing consultants in the ED to undertake awareness sessions regarding the recognition and investigation of CES, and share the case at the Clinical Board Quality Safety and Experience meeting and the Morbidity and Mortality departmental meeting to promote discussion and learning.

In light of these agreed actions the investigation was brought to a close.