Report Date


Case Against

Cardiff and Vale University Health Board


Clinical treatment in hospital

Case Reference Number



Not Upheld

Mrs G complained about Cardiff and Vale University Health Board’s (“the Health Board”) care, treatment and actions following her daughter’s, Mrs D, endoscopic retrograde cholangiopancreatography (“ERCP” – an examination of the pancreatic and bile ducts using a thin tube with a light and camera on the end). Mrs G said it caused her daughter internal bleeding, further health complications, and led to her premature death 6 weeks later.

The Ombudsman’s investigation found that whilst the ERCP procedure carried out by a Radiologist caused Mrs D to suffer a splenic bleed, which is a very rare occurrence, this was an accepted known risk of the procedure and Mrs D was made aware of this risk beforehand. The Ombudsman could find no evidence that the Radiologist was at fault.

Finally, the Ombudsman concluded that whilst Mrs D’s splenic bleed complicated her subsequent treatment following her previous diagnosis of pancreatic cancer, timely and appropriate action was taken, especially when Mrs D suffered pulmonary embolisms.

The Ombudsman did not uphold Mrs G’s complaint.