Report Date


Case Against

Cwm Taf Morgannwg University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Mr A complained that an extended excision of a skin lesion on his left arm that he underwent at Neath Port Talbot Hospital on 8 July 2013 (following an initial excision on 30 April 2013 that had identified a stage 1 malignant melanoma) was improperly conducted and failed to completely remove all the cancerous tissue.

The Ombudsman was unable to reach a finding on whether the correct margin of skin was taken during the procedure on 8 July 2013. However, the investigation found that there was a failure to document the recommended margin when the procedure was requested and that this contributed to the lack of corresponding detail in the operation note. The complaint was upheld to the limited extent that the resulting uncertainty about whether appropriate care was provided was an injustice to Mr A.

The Health Board agreed to implement the Ombudsman’s recommendations to apologise to Mr A for the failings identified and share the investigation report with the Clinical Director responsible for its dermatology service and with members of its skin cancer Multidisciplinary Team.