Report Date


Case Against

Cwm Taf Morgannwg University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Mrs Y complained that Cwm Taf Morgannwg University Health Board did not provide appropriate assessment, care and treatment to her late daughter, Ms X, on 28 March 2020.

The investigation found that it would have been routine and standard practice for the assessment Ms X received in the Emergency Department (“ED”) to have excluded a diagnosis of heart disease, including taking a Troponin blood test, before her discharge. If the Health Board had properly followed its own acute coronary syndrome diagnosis Proforma, Ms X would have been categorised differently and should have received a Troponin blood test. It was not reasonable to discharge Ms X without having completed that blood test. Had the blood test been undertaken, it was likely Ms X would have been at hospital when she suffered a cardiac arrest. Although the investigation could not definitively determine that Ms X would have survived the cardiac arrest had she been in hospital when it occurred, she was more likely to have done so. This uncertainty caused the family an injustice. The investigation also found that the complaint response sent to Mrs Y was neither fair nor transparent.

The Ombudsman recommended that within 2 months, the Health Board should offer a clear, sincere and unqualified apology for the clinical failings identified in the report and apologise for the inaccuracies in the response to Mrs Y’s complaint. He recommended that within 6 months, the Health Board should remind all Emergency Doctors of the importance of taking and recording a full clinical history from patients, and offer training to all Emergency Doctors on the local chest pain pathway.