Report Date


Case Against

Cardiff and Vale University Health Board


Clinical treatment in hospital

Case Reference Number



Not Upheld

Mrs Y was 69 years old and on 7 December 2021 she was admitted to hospital with abdominal pain, diarrhoea and vomiting. Mr S complained about Mrs Y’s treatment between 7 and 12 December 2021. The Ombudsman found that the delay Mrs Y faced in being placed on a ward was not detrimental to her as she had received ongoing care. She also found that it was unlikely that Mrs Y suffered a perforated bowel on 7 December, as a CT scan had not shown free air within the abdomen and her management was appropriate for the diagnosis of an uncomplicated diverticulitis.
The Ombudsman found that on 11 December Mrs Y’s differential diagnosis included the possibility of a perforation, which led to further reviews and a CT scan that showed Mrs Y had experienced a perforation. It was found that this was the earliest opportunity to have identified the perforation, with no delay in its diagnosis. When consent was sought, Mrs Y was appropriately warned that the proposed procedure had a 43.3% risk of mortality. Mrs Y consented to a laparotomy for Hartmann’s procedure (to remove the diseased part of the large bowel to form a new opening for bowel contents), which she underwent on 12 December. The Ombudsman found that Mrs Y’s treatment between 7 and 12 December was appropriate and timely. Sadly, Mrs Y died on 26 December. The complaint was not upheld.