Report Date


Case Against

Hywel Dda University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Ms B complained that Hywel Dda University Health Board failed to provide appropriate care and treatment to her late mother, Mrs C. In particular, Ms B complained that the Health Board failed to provide Mrs C with timely anti-tuberculosis (“TB”) treatment.

The Ombudsman’s investigation found that Mrs C’s CT scan was dealt with appropriately and the time frame from the CT scan until the bronchoscopy was reasonable. She found that even had the bronchoscopy been performed earlier, this would not have changed the eventual outcome for Mrs C. The Ombudsman found that there was a7-day delay in Mrs C receiving anti-TB treatment. This was a service failure. While the Ombudsman found that it was unlikely starting the TB treatment 7 days earlier would have prevented Mrs C’s deterioration, admission, and subsequent death, she concluded that the 7-daydelay led to uncertainty and caused distress for Ms B and her family. The Ombudsman found that it was upsetting for Ms B and her family to know that there was a 7-day period in which Mrs C could have commenced treatment and that the Health Board did not do all that it should have done to attempt to make Mrs C well. This was an injustice, and it is to this extent the Ombudsman partly upheld Ms B’s complaint.

The Ombudsman recommended that the Health Board, within one month, should share the report with the relevant clinicians for reflection and learning. The Ombudsman also recommended that the Health Board should update the Ombudsman, at least every two months, on its compliance with the recommendations set out in the Public Health Wales and Health Board’s joint report into its handling of the TB outbreak. Once completed, the Health Board should confirm to the Ombudsman that it has complied with the recommendations of the Review.