Report Date


Case Against

Cwm Taf Morgannwg University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Mrs A complained about the management and care she received from Prince Charles Hospital’s (“the Hospital”) colorectal team and particularly the Colorectal Nurse Specialist (“the CNS”) in relation to her faecal incontinence from December 2017 onwards. Mrs A also questioned whether a referral for a surgical opinion concerning her faecal incontinence should have occurred sooner as well as highlighting inadequacies in clinical communication especially in relation to the surgical referral. Finally, Mrs A was dissatisfied with aspects of the Health Board’s handling of her complaint.

The Ombudsman concluded that aspects of Mrs A’s faecal incontinence management and care, as carried out by the colorectal team and the CNS in particular, was in keeping with the relevant National Institute for Health and Care Excellence’s (“NICE”) guidance. However, the Ombudsman found administrative failings, which included medical records not supporting referrals being made to the pelvic floor multi-disciplinary team. This, along with communication by both the CNS and the colorectal nursing team with Mrs A, not always being as effective as it could have been, also had an impact. The Ombudsman could not rule out that more timely referrals might have resulted in a colorectal surgical opinion being sought and obtained sooner. She also found inadequacies in the Health Board’s complaint handling which included the complaint response being insufficiently robust. The Ombudsman upheld Mrs A’s complaints to varying extents. She found that Mrs A had been caused an injustice, both in terms of the impact on Mrs A’s quality of life, as well as the uncertainty and anxiety the shortcomings in Mrs A’s management and care had on her. The fact that Mrs A had to complain further in order to obtain answers added to the injustice caused to her.

The Ombudsman’s recommendations included an apology to Mrs A, as well as the reimbursement of the cost of a private consultation Mrs A had with a colorectal surgeon. The Health Board was also asked to provide an update to Mrs A regarding her colorectal surgeon referral. In addition, the Health Board was asked to consider and/or implement various administrative and operational recommendations relating to record keeping improvements, communication and clinical management of faecal incontinence.