Report Date


Case Against

Cwm Taf Morgannwg University Health Board


Clinical treatment in hospital

Case Reference Number



Not Upheld

During 2018 Mrs X was twice admitted to the Royal Glamorgan Hospital (“the Hospital”) and diagnosed with pancreatitis. In August 2019 Mrs X was admitted with pancreatitis and a CT scan showed a gallstone impacting the gall bladder, but her pancreas could not be seen because of overlying bowel gas. In December Mrs X had a laparoscopic cholecystectomy. On 17 March 2020 Mrs X was admitted to the Hospital with abdominal pain and tests showed that the bile duct was grossly dilated, a large gallstone was seen at the end of the common bile duct and a stent was inserted. Mrs X was discharged on 27 March. On 3 August Mrs X was admitted with a suspected blocked stent, and on 7 August Mrs X had a CT scan that diagnosed pancreatic cancer. Mrs X complained about whether her discharge from the Royal Glamorgan Hospital on 27 March 2020 was appropriate and whether her terminal pancreatic cancer should have been diagnosed before 7 August 2020. Sadly, Mrs X died on 24 October 2022.

The Ombudsman found that Mrs X’s discharge on 27 March 2020 was reasonable. She also found that the cancer could not have reasonably been expected to be diagnosed before 7 August 2020. Mrs X’s complaints were not upheld.