Report Date


Case Against

Cwm Taf Morgannwg University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Mr B complained about the care provided to his daughter, Ms E, when she was suffering from recurrent rectal prolapses between February and August 2019. The investigation considered whether:
a) There was a failure to recognise how Mr B’s ability to support Ms E in the community was impacted by her medical needs.
b) There was a failure to offer support and make referrals to enable support and/or advice to be obtained.
c) Substandard advice was given concerning Ms E’s bowel management, laxative and dietary requirements.
d) Mr B was advised on numerous occasions to manually push Ms E’s prolapse back into position.
e) On numerous occasions Mr B and Ms E experienced lengthy delays in the Emergency Department (“the ED”) while waiting to be reviewed by the on call surgical team (“the Surgical Team”).
f) The Health Board’s complaint response was insufficiently robust and, therefore, lessons were not learned from Mr B’s complaint.

The Health Board has a Service Level Agreement (the provision of a specific and discrete element of health care services) with Swansea Bay University Health Board with regard to its Community Learning Disability Health Team (“the Learning Disabilities Service”).
The investigation found that there was a lack of action and collaborative working from the Learning Disabilities Service and a delay in the Consultant Surgeon reviewing Ms E after her appointment in May. There was a failure of the Health Board to consider and arrange psychology input to support behavioural modification and anxiety management for Ms E around eating and toileting between February and August 2019. The Consultant Surgeon was the appropriate clinician to advise on laxative use and diet and the management plans were appropriate. There was no recognition of the fact that Mr B assisting in reducing Ms E’s prolapse at home was a very intimate procedure. The Consultant Surgeon could have done more to establish whether Mr B was comfortable with the advice given and manage his expectations about what support was available from the Health Board (which, save for attending the ED, was very little). The lengths of time Ms E waited in the ED for the Surgical Team were clinically appropriate in the circumstances.

There was a failure to deal with the support aspect of Mr B’s complaint and there was no acknowledgement of the level of stress and strain placed on the family during an extremely difficult few months. This meant that Mr B was not assured that a robust investigation had been undertaken or that appropriate action would be taken to ensure that lessons could be learnt.

Accordingly, paragraphs a) and f) were upheld and b) and d) were partially upheld.
The Health Board agreed to provide Mr B with an apology for the failings identified, pay him a sum of £500 in recognition of the clinical failures identified and a sum of £250 specifically in recognition of the poor complaint handling. It agreed to invite the Consultant Surgeon and the Psychiatrist in Intellectual Ability to reflect upon the contents of the report and discuss its findings at their next annual appraisals.

In consultation with Swansea Bay University Health Board, there was an agreement that the Learning Disabilities Service should produce a summary document of their service specification and remit as it continues to provide Positive Behavioural Support training to key staff and guidance on the triggers for involvement from the disability liaison nurses based in the acute hospital.