Report Date


Case Against

Cwm Taf Morgannwg University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Miss D complained that in November 2021 Cwm Taf Morgannwg University Health Board missed opportunities to identify that her daughter, E, was suffering from appendicitis (inflammation of the appendix, a finger shaped pouch at the lower right side of the abdomen).

The Ombudsman’s investigation found that the Health Board’s clinicians would not have been expected to consider appendicitis as a potential diagnosis between 13 and 21 November 2021, taking into account E’s symptoms at the time. However, there was a failure to ensure that the decision to discharge E on 14 November was reviewed by a doctor with appropriate paediatric experience. While the investigation did not find that a more senior clinician would have taken a different approach, or that this would have led to an earlier identification of E’s appendicitis, it found that the lost opportunity for a further review was an injustice to E. To that limited extent, the complaint was upheld.

The Health Board agreed to the Ombudsman’s recommendations. These included to apologise to Miss D and to remind all its Medical Teams that children should not be discharged without an appropriately senior review. It also agreed to carry out a Health Board-wide review of existing policies, procedures and guidance in place to support the prompt identification and treatment of appendicitis and take appropriate action to address any improvements needed in light of the previous concerns which have arisen about the Health Board’s performance in this area.