Report Date


Case Against

Hywel Dda University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Mr A complained about the care and treatment his wife, Mrs A, received from Hywel Dda University Health Board’s Glangwili General Hospital (“the Hospital”) when she underwent a Trans Oesophageal Echocardiogram (“TOE” – where a thin ultrasound probe is swallowed to allow a detailed ultrasound examination of the scanned heart from within the food pipe) on 29 October 2019. He also complained about his wife’s management when she attended the Emergency Department (“ED”) and the failure to detect her stroke, infected spleen, spine, heart valve and small brain haemorrhages caused by the TOE. He also had concerns about his wife’s medical and nursing management and care during her inpatient admission, the effectiveness of communication with him and his wife, as well as the Health Board’s handling of his complaint.

The Ombudsman’s investigation found that apart from some documentary failings, the 29 October procedure was carried out appropriately and would not have caused the stroke and other complications that Mr A subsequently complained about. Likewise, appropriate tests and investigations had been carried out when Mrs A attended the ED on 13 November. These parts of Mr A’s complaint were not upheld. The Ombudsman concluded that aspects of Mrs A’s medical and nursing care during an inpatient admission were reasonable, although there were issues identified around the management of Mrs A’s nutrition, catheter care and bowel management and to that extent the complaint was upheld. Documentary shortcomings in the TOE procedure which impacted on communication as well as shortcomings in complaint handling also led the Ombudsman to uphold these parts of Mr A’s complaint. The Ombudsman’s recommendations included the Health Board apologising to Mr and Mrs A and taking steps to address documentary failings in relation to the TOE as well as the nursing shortcomings identified.

Additional training was also recommended around catheter care and introducing a lower threshold for decisions about patient conscious sedation.