Report Date


Case Against

Cwm Taf Morgannwg University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Mrs P complained about the assessment and examination her adult son, Mr Q, received when he attended the Emergency Department of the Prince Charles Hospital on 30 October 2020. Mrs P said he was not examined thoroughly as 4 days later Mr Q was admitted to a hospital in England and following tests it was discovered he had lesions on his brain.

The Ombudsman’s investigation found that whilst Mr Q underwent a comprehensive assessment in the Emergency Department, his symptoms of headache and unsteadiness on his feet were not investigated further. If they had, it was more likely than not that Mr Q would have undergone a CT scan sooner and the lesions on his brain might have been diagnosed a few days earlier. This was an injustice to Mr Q and the Ombudsman upheld Mrs P’s complaint.

he Ombudsman recommended that the Health Board apologise to Mrs P and share the report with the staff in the Emergency Department to highlight the service failure and remind staff to look for patients with symptoms like Mr Q’s. The Health Board agreed to the recommendations.