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 about the care and treatment her late husband, Mr A, received from Cwm Taf Morgannwg University Health Board (“the Health Board”). The investigation considered whether an earlier referral to vascular surgeons was indicated based on Mr A’s presentation with severe abdominal pain, sickness, and associated weight loss from September 2020.

The investigation found that Mr A should have been investigated earlier for intestinal ischaemia (when blood flow to and from the intestines slows or stops) by computerised chromatography (“CT scan” – the use of X-rays and a computer to create an image of the inside of the body) angiography (a CT scan combined with an injection of a special dye to produce pictures of blood vessels and tissues) and that if he had been, a diagnosis would have been made. It is possible that Mr A could have had a confirmed diagnosis and referral to the Vascular Surgeons as early as September 2020. Mr A was not referred to the Vascular Surgeons until December 2021. The Ombudsman upheld the complaint.

The Health Board agreed to provide Mrs A with a meaningful apology for the failings identified. Additionally, it agreed to present the Ombudsman’s findings at its Morbidity and Mortality meeting, with reminders to ensure that uncommon diagnoses are considered in persistent cases with no established diagnosis and that the role of the radiologist is to provide a report with findings and if possible a potential diagnosis, but it is the clinical team that is responsible for both establishing a diagnosis and treatment based on having all the information that is often not available to a radiologist.