Report Date

04/09/2024

Case Against

Cwm Taf Morgannwg University Health Board

Subject

Clinical treatment in hospital

Case Reference Number

202207172

Outcome

Upheld in whole or in part

Mrs A complained that Cwm Taf Morgannwg University Health Board failed to properly investigate her son, Mr B’s, complaints of chest pain, and provide him with appropriate care and treatment, during each of his 3 attendances at the Royal Glamorgan Hospital in September 2021.

The Ombudsman found that Mr B should not have been discharged from the Emergency Department(“ED”) on 7 September. Investigations led clinicians to believe he might be suffering from a rare heart condition but did not refer him to cardiology colleagues for further assessment or treatment. Fortunately, Mr B returned to the ED within a matter of hours, following which he was admitted and received appropriate investigations and care. Mr B returned to the ED on 17 September, where he underwent tests which suggested he might have ischaemic heart disease (when the heart’s blood supply is blocked or interrupted by a build-up of fatty substances in the coronary arteries) and might have suffered a recent heart attack. The Ombudsman concluded that, at that point, Mr B should have been referred to the Acute Medicine or Cardiology teams for admission and consideration of further investigations and treatment, but he was discharged without any referral being made. Very sadly, Mr B died at home a couple of weeks later. Although the Ombudsman could not say Mr B would have survived if it were not for the failings identified, Mrs A would be left with the uncertainty that he might have done and this was a significant injustice to her. As a result, the Ombudsman upheld the complaint.

The Ombudsman recommended that the Health Board apologised to Mrs A for these failings and offered a payment of £1000 in recognition of the uncertainty these caused. The Ombudsman also recommended that the report was shared with the teams involved in Mr B’s care for reflection and learning, and that the case was discussed at a Quality and Safety meeting to consider whether there were any wider actions or improvements that could betaken forward.