Report Date


Case Against

Cardiff and Vale University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Mrs X complained about treatment she received for repeat infections of the Prolene mesh (a loosely woven sheet used as either permanent or temporary support for tissue during surgery) in her abdominal wall. The mesh was first inserted many years previously, and she had undergone several surgical procedures to remove bits of the mesh but Mrs X’s complaint centred on her clinical care between 2018-2019 and delays in treatment within that period. Her repeat infections meant that Mrs X’s wound, once excised and drained of fluid, was left open and, she said, often weeping into her clothing, which distressed her greatly.

The investigation found that, overall, Mrs X’s clinical care was to a reasonable standard. Prolene mesh is often removed in pieces, when necessary, as it links to tissue in the interim, so is impossible to remove as a whole. When infection happens, it often proves difficult to resolve completely and so becomes chronic, as in Mrs X’s case. Whilst acknowledging Mrs X’s distress, leaving the wound open to heal is accepted good practice. The Adviser appointed by the Ombudsman to review Mrs X’s case was critical of one attempt to close the wound after draining the fluid in 2018, describing it as “inadvisable”. Due to Mrs X’s ongoing repeat problems by then it was likely she would still have continued to suffer them so this aspect of the complaint was not upheld. The investigation found that there had been an 8 week delay in Mrs X undergoing a further procedure in late 2018, despite her referral being urgent. This was caused by lack of clarity in the communication between 2 hospital departments and a delay in response from a clinician at another hospital (relating to another condition Mrs X suffered from). In the context of a procedure required urgently, and that her situation was causing Mrs X distress, this was an injustice to her. This aspect of delayed care was upheld.

The Health Board agreed to the Ombudsman’s recommendations to (i) apologise to Mrs X for the delay identified in undergoing a procedure in 2018 and (ii) to review the reasons for that delay so as to learn lessons and improve its internal communication processes, to avoid repetition.