Report Date


Case Against

Cardiff and Vale University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Mr C complained about the care and treatment his late wife, Mrs C, received from Cardiff and Vale University Health Board (“the Health Board”) between November 2021 and March 2022. He said the Health Board missed opportunities to diagnose her brain tumour earlier. In particular, we investigated whether Mrs C’s computerised tomography scan (“CT scan” – the use of X-rays and a computer to create an image of the inside of the body) on 15 November 2021 was correctly interpreted, whether Mrs C underwent appropriate tests on 5 January 2022 and if she was discharged appropriately and whether, during Mrs C’s last admission, she was assisted appropriately with eating food, and whether Mr C was informed that extra visitations were possible as she was at end-of-life.

The investigation found that the CT scan taken on 15 November 2021 was interpreted correctly and this part of the complaint was not upheld.

The Ombudsman found that although Mrs C was well enough to be discharged, her facial swelling was not investigated further. Had it been, an earlier diagnosis of cardiac angiosarcoma would have been made and Mrs C would have remained under the care of the Health Board. This part of the complaint was upheld.

During Mrs C’s last admission, there were missed opportunities to complete numerous templates to evidence her nursing care in relation to nutritional assessment, provision of nutrition and assistance with eating and drinking. There were also missed opportunities to robustly complete strict fluid intake and output monitoring. Finally, in relation to extra visitations, whilst there was evidence of a discussion taking place with Mr C regarding extended visiting arrangements, Mrs C would have benefitted from this if this had been initiated sooner. This part of the complaint was also upheld.
The Ombudsman recommended that the Health Board apologise to Mr C, reimburse him the sum of £2,022 to cover the private consultations and scans and share the report at the Hospital’s Medicine Quality and Safety meeting. The Ombudsman also recommended that staff were reminded of their responsibilities, in line with their professional obligations, to ensure documentation relating to nutrition and fluid balancing is monitored and documented correctly, and of the importance of clear documentation and evidence of communication with relatives is noted.

The Health Board agreed to carry out the Ombudsman’s recommendations.