Report Date


Case Against

Cardiff and Vale University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Mrs W complained about the care and treatment her son, Y, received from Cardiff and Vale University Health Board between his birth in August 2017, and December 2022. Specifically, she complained that the Health Board failed to carry out appropriate investigations and tests to diagnose Y with a bowel duplication and recto-urethral fistula (where a small hole forms between the urethra and rectum) and failed to refer Y to a specialist hospital at the appropriate time.

The investigation found that there was a delay in Y receiving a diagnosis for his symptoms and this complaint was upheld. It was also found that while it was appropriate to refer Y to a specialist hospital in August 2022, when faeces was found in his urine, it would have been appropriate to refer him earlier due to his ongoing unexplained symptoms. This complaint was also upheld.

The Health Board agreed to apologise to Mrs W for the failings identified and make a financial redress payment of £1000 in recognition of the stress and continued discomfort caused by the delay in carrying out appropriate tests and requesting a second opinion. It also agreed to share the final report with relevant clinicians, remind them of the need to have multi-disciplinary team meetings with all relevant clinicians and all images available for children with complex issues, and remind them that for complex children where there is no improvement in symptoms to seek a second opinion.