Report Date


Case Against

Cwm Taf Morgannwg University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Ms F complained that, during her pregnancy, the Health Board failed to access her previous maternity records, despite repeated requests from her, and failed to follow the correct procedure for retrieving them. Ms F was concerned that there might have been a racial motive in the Health Board failing to make her records available. Ms F also complained that the Health Board failed to provide copies of her previous records to a Second Health Board that took over her care. She further complained that the Health Board failed to provide her with counselling in line with its normal process for women who previously had a caesarean section, and that her Consultant expressed the view that a normal delivery should be appropriate without seeing her previous records.

The Ombudsman found no evidence that midwifery staff requested Ms F’s previous notes or flagged them as missing as they should have done, and the Health Board acknowledged that the midwives concerned were unaware of the correct process. The Health Board did not locate the records until after Ms F’s baby was born, when they were found in its archived medical records department. The Ombudsman found that the failure to follow the correct processes and to carry out timely and thorough searches for the records was maladministration. These failings caused significant worry to Ms F, who was very anxious due to her previous emergency caesarean section. The Ombudsman upheld the complaint, although he found no evidence of racial discrimination in the actions of staff. He also upheld the complaint about the failure to provide Ms F’s past records to the Second Health Board, which caused her additional worry and anxiety.

The Ombudsman did not find any shortcomings in the counselling provided by Ms F’s Consultant, which focused on the general risks and benefits of a natural delivery. However, Ms F should have had the opportunity to review her previous experience of pregnancy and birth with an obstetrician. The failure to access her records meant that she was denied that opportunity, which caused her distress and anxiety and affected her ability to make an informed choice about birth planning. The Ombudsman upheld the complaint on that basis.

The Ombudsman noted that Ms F did not have any factors that would preclude a normal delivery, and he did not uphold the complaint about the view expressed by Ms F’s Consultant.

The Ombudsman recommended that within a month of the report, the Health Board apologise to Ms F and pay her £500 to reflect his findings.