Report Date


Case Against

Cardiff and Vale University Health Board


Clinical treatment in hospital

Case Reference Number



Voluntary settlement

Dr B complained about the care and treatment she received from Cardiff and Vale University Health Board (“the Health Board”) before, during and after the birth of her first child on 1 March 2021. The investigation considered whether the available indications that Dr B’s baby was likely to be significantly larger than average were taken into sufficient account when planning and assisting her labour, and if more should have been done to start/progress her labour faster, including an induction and/or caesarean section. It also considered whether there were any indications that foreign material was left in Dr B’s uterus after the caesarean section, and if the complaint response provided by the Health Board was appropriate.

The investigation found that, while Dr B’s labour was extended, the care and treatment provided to her was in line with relevant guidance. Although the material she had passed post birth was never conclusively identified, there was not sufficient evidence to find that it was likely to be due to foreign material left after the caesarean section. As a result, these elements of the complaint were not upheld. However, the investigation identified some issues in the complaint responses provided by the Health Board, and so this aspect of the complaint was upheld.

The Ombudsman recommended that the Health Board should apologise to Dr B for the issues identified and remind the Clinical Board complaints handling staff of the importance of reviewing complaint responses to ensure consistency and accuracy.