Report Date


Case Against

Cwm Taf Morgannwg University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Ms A complained about her late father, Mr E’s management and care during his short inpatient admission at the Princess of Wales Hospital in March 2020, and the fact that his bowel cancer was not identified. She also said that her father had been discharged home in a worse state of health than when he went in with no follow-up post discharge appointment. Finally, she raised concerns about the adequacy of Cwm Taf Morgannwg University Health Board’s (“the Health Board’s”) complaint response.

The Ombudsman found failings in Mr E’s management and care when a small bowel obstruction (SBO) was identified. Although Mr E’s management and care was initially appropriate, when his symptoms continued he should have been given a contrast CT scan, which would have identified his bowel cancer as the underlying cause of his bowel obstruction, as well as having in person senior surgical reviews. The Ombudsman was critical of the futile daily enemas administered to Mr E in the latter stages of his admission which exceeded recommended daily prescribing guidance, and impacted on Mr E’s comfort and dignity. The Ombudsman concluded that the delayed cancer diagnosis and unnecessary enema treatment caused Mr E and his family an injustice and upheld this part of the complaint.

The Ombudsman found that Mr E’s condition had improved, in that his acute kidney injury and vomiting had resolved and he was eating and drinking at the time he was discharged. Given this and the fact post discharge follow-up appointments for SBO were not usual, this part of the complaint was not upheld.

The Ombudsman identified administrative failings in complaint handling and the robustness of the complaint response which led to Ms A having to complain further to obtain answers, causing her an injustice. He upheld this part of the complaint.

The recommendations to the Health Board included an apology letter, discussing Mr E’s case for wider learning at a surgical audit meeting and carrying out a complaint handling review.