Report Date


Case Against

Cwm Taf Morgannwg University Health Board


Clinical treatment in hospital

Case Reference Number



Voluntary settlement

Ms A complained about the care given to her by Cwm Taf Morgannwg University Health Board. She said that the Health Board had left a cannula (a thin tube that is put into a vein to enable fluid and medication to enter the bloodstream directly) in her left arm for longer than was necessary. She reported that it had then failed to completely remove that cannula. She also said that it had taken too long to address her concerns about the pain in her left arm after the cannula’s removal.

The Ombudsman found that the Health Board had left a piece of cannula in Ms A’s left arm for several days despite relevant clinical standards (“the Standards”) and Ms A’s concern about her cannula. He also found that the Health Board had failed to complete the documentation related to Ms A’s cannula properly. He noted that a Health Board employee had indicated that Ms A had had to have further surgery and remain in hospital for longer because of failings related to the Health Board’s management of her cannula. He was also concerned that the Health Board had not considered the issue of qualifying liability (harm caused by, or in connection with, the care provided) properly when it investigated Ms A’s concern about her cannula. He was of the view that Ms A had suffered an injustice, in the form of pain, distress and inconvenience, because of the failings identified.

The Ombudsman decided that it would be appropriate to try settling Ms A’s complaint. The Health Board subsequently agreed to write to Ms A to apologise for its inadequate complaint handling and to confirm that it would consider her concerns, about her cannula-related care, in a manner akin to the redress arrangements outlined in the relevant complaint handling regulations. It also agreed to consider Ms A’s concerns in that way and to share the cannula-related lessons learned from her experience with all relevant staff and to remind them of the Standards. The Ombudsman considered that the action that the Health Board had agreed to take was reasonable. Accordingly, he regarded Ms A’s complaint as settled.