Report Date


Case Against

Hywel Dda University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

On 1 December 2011 Mr X’s ultrasound scan reported liver changes indicative of cirrhotic change. In April 2014 a Consultant Haematologist wrote to the GP that Mr X had cirrhosis of the liver and he should be cared for by gastroenterologists. In November Mr X’s CT scan reported a lesion with known cirrhosis. In February 2015 Mr X’s CT scan concluded there was cirrhotic change but no lesion was seen within the liver. In 2018 he agreed to a shoulder replacement. In January 2019 it was noted that Mr X had cirrhosis which had not been followed up. Mr X’s shoulder was replaced in June. After this procedure Mr X suffered swelling to his leg and abdomen and he was referred to gastroenterology. In August Mr X was seen by a Consultant Gastroenterologist, who noted that the 2011 liver cirrhosis and the 2014 and 2015 scans that identified liver lesions that were not referred. On 7 August Mr X’s CT scan reported findings of Hepatocellular Carcinoma. On 4 September Mr X was told his treatment would be palliative. On 26 September Mr X died of liver cancer. Mrs X complained that the liver cancer should have been diagnosed before August 2019.

The Ombudsman found that Mr X’s 2011 ultrasound scan should have been followed up by referral to liver services and by the time of the 2014 and 2015 scans he should have been referred for monitoring, blood tests and scans to have identified the liver cancer. The Ombudsman found that in 2014 Mr X should have been referred to gastroenterology or hepatology. It was also found that Mr X’s liver cancer should have been identified before 2019, and by this time there were no treatment options available. The Ombudsman upheld the complaint.

The Health Board agreed to implement the Ombudsman’s recommendations within 1 month, to apologise to Mrs X and make a redress payment of £4,000. The Health Board agreed, within 6 months, to review guidelines and links with primary carers to ensure good knowledge of liver disease and pathways for referral, to remind staff of their responsibility to arrange further patient referral, and to outline to the Ombudsman steps taken to prevent a recurrence.