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 to the Ombudsman about the treatment her mother, Mrs B, received from Velindre University NHS Trust(“the Trust”), Cwm Taf Morgannwg University Health Board (“the First Health Board”) and Swansea Bay University Health Board (“the Second Health Board”). Mrs B was diagnosed with asarcoma (a rare type of cancer). She was referred to a specialist Sarcoma Multidisciplinary Team (“MDT”- a team comprising of specialist doctors and nurses who meet to establish a patient’s diagnosis and treatment).

Mrs B underwent radiotherapy(the use of radiation to kill cancer cells), in preparation for surgery under a surgeon at the Second Health Board. A CT scan taken just before the surgery later showed that the disease had progressed. Mrs B remained under the care of the First Health Board, the Second Health Board and the Trust during the treatment of her sarcoma. It was later identified that the cancer had spread to her lungs and that this was considered to be uncurable. Plans for chemo therapyas a palliative measure was delayed because of the Covid pandemic. Sadly Mrs B died on 1 October 2020.

The investigation looked at whether the Trust failed to communicate appropriately with Mrs B and her family; missed an opportunity for earlier treatment; and failed to treat a potential infection following a blood test result. The Ombudsman also considered whether the first Health Board failed to appropriately investigate the possibility of an infection following Mrs B’s admission to hospital.

Finally, the investigation looked at Mrs A’s complaint that the second Health Board failed to inform her of abnormal lesions found on Mrs B’s CT scans and failed to treat those lesions. The investigation also considered whether the Second Health Board failed to provide appropriate post-operative physiotherapy care and whether it maintained Mrs B’s medical records to an appropriate standard.

The investigation found that the clinical care provided by all three bodies was of an appropriate standard. However, the Ombudsman found, that there had been failings in the manner in which the Trust and the Second Health Board had communicated with Mrs B and her family. The Ombudsman also found, in relation to the Second Health Board that the standard of record keeping had been poor. He upheld these elements of Mrs A’s complaints.

The Ombudsman recommended that the Trust and the Second Health Board each pay £250 redress to Mrs A for the poor communication. The Ombudsman also recommended that the Second Health Board pays a further redress £250 for its poor record keeping. The Ombudsman made a number of further recommendations to the Trust and the Second Health Board, to be implemented and shared with the Ombudsman within three months, to ensure that lessons were learned from the failings highlighted by this report. The Ombudsman also recommended that the Second Health Board reminded its clinical staff of their obligation to maintain documentation that is clear, concise and comprehensive record of care, alongside the formulation of an improvement plan.