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 found that overall, the care and treatment provided to Mr B at the First Hospital between 3 and 8 May 2022 was appropriate. The Ombudsman did not uphold complaints a) to c). The diagnosis and management of Mr B’s bowel obstruction was also considered to be reasonable and appropriate during that period. However, it was not considered appropriate to send Mr B home at 01:00 on 4 May following initial consideration of his investigative scan, with instructions to return to the First Hospital at 10:00 for further review. There was no indication of clinical harm to Mr B in this respect, but it was an injustice to him and to his family that appropriate care and consideration was not given to his circumstances at that time. To that limited extent only, this element of complaint d) was upheld

I recommend that, within 1 month of the date of this report, the Health Board should:

a) Apologise to Mr B’s family for the failures identified in this report

b) Ensure that this report and its findings are shared with staff within the SAU unit, to enable staff reflection on the failing identified.