Report Date


Case Against

Cardiff and Vale University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

The Ombudsman investigated a complaint made by Ms B, regarding the care and treatment her late mother, Mrs C, received from Cardiff and Vale University Health Board. In particular, Ms B was concerned that Mrs C was not provided with appropriate information and medication in preparation for her capsule endoscopy procedure (where a small capsule sized camera is swallowed and captures images as it moves through the digestive tract, to enable examination of the lining of the small bowel),and that Mrs C’s history of diabetes was not appropriately assessed by clinical staff on 8 June 2021 both prior to, and following, the procedure. Ms B also complained that the laxative bowel preparation provided to Mrs C prior to the procedure ultimately caused her death.

The investigation found that although the bowel preparation medication provided to Mrs C in advance for her capsule endoscopy was appropriate, the information provided to her about diabetic medication management (including the impacts and implications of that) and the need to seek advice from her diabetic specialist nurse, was not adequately documented. Neither was Mrs C’s high blood sugar level re-checked on the day of her procedure, to identify if any further assessment or intervention was required and whether Mrs C was fit to proceed. The Health Board failed to meet an appropriate standard of care in those respects and these complaints were upheld. The Ombudsman was unable to make a finding on whether the bowel preparation ultimately caused Mrs C’s death. This is not something the Ombudsman can consider and determination of the cause of death is the legal function of the Coroner.

The Ombudsman recommended that the Health Board apologise for the failings identified and that it should review its clinical guidelines for endoscopy to ensure appropriate diabetic advice and medication assessment is addressed. It was recommended that the pre procedure assessment questions and the patient information leaflet be updated to ensure a patient’s diabetes regime is fully documented, risks and implications discussed, and responsibilities for seeking further diabetic specialist advice are made clear. The Ombudsman also recommended the development of a form for the day of the procedure, confirming the patient is fit to proceed with a capsule endoscopy. It was also recommended that suitably qualified clinicians should also be involved in future safety meetings or case reviews involving complicated medication regimens involving insulin, injectable treatments and oral medications.