Report Date


Case Against

Cardiff and Vale University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Mrs Y complained about the care and treatment received by her daughter, Z, from Cardiff and Vale University Health Board (“the Health Board”). Specifically, Mrs Y complained that the Health Board did not assess or investigate her daughter’s symptoms appropriately when she presented to the University Hospital of Wales between 10-12 May 2022, thereby leading to a failure to diagnose her adult bowel malrotation (when the bowel twists and causes a blockage) in a timely manner and that it did not handle her complaint appropriately.

The investigation found that Z’s symptoms were not assessed or investigated appropriately on the first 2occasions she attended the Hospital. Record keeping relating to Z’s care was not of an acceptable standard and a referral to a clinic for further tests was not made. These are service failures and led to an avoidable delay in Z being diagnosed with adult bowel malrotation. The investigation also found that Mrs Y’s complaint was not handled appropriately, and she was given unrealistic expectations for when she was likely to receive a response to her complaint. This is a failing and a source of great frustration to Mrs Y. Both parts of Mrs Y’s complaint were upheld.

The Ombudsman recommended that the Health Board should apologise to Mrs Y and offer her financial redress in recognition of the failures identified in the investigation. The Ombudsman also recommended that the Health Board should undertake a review of the referral process for the clinic and ensure that there is a system in place to identify when comments on complaints are overdue.