Report Date


Case Against

Hywel Dda University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Mrs A complained about the care and treatment Hywel Dda University Health Board provided to her late husband, Mr A. Specifically she complained that the Health Board failed to identify an abdominal aortic aneurysm on a scan that her late husband underwent, and that this failure meant that he failed to receive appropriate treatment prior to his death from a ruptured abdominal aortic aneurysm.

The investigation found that the abdominal aortic aneurysm was visible on the scan that Mr A underwent and should have been noted and reported on. As such the Ombudsman upheld this part of Mrs A’s complaint. This failure by the Health Board meant that Mr A did not receive appropriate treatment for the abdominal aortic aneurysm. This part of Mrs A’s complaint was also upheld.

The Health Board agreed that it would apologise to Mrs A for the failings identified in the investigation. It also agreed that the radiologist that reported on Mr A’s scan would reflect on this event in their next review meeting and that the imaging would be shared at the local Radiology Events and Learning Meeting for shared discussion and learning. In addition, the Health Board also confirmed that it had reviewed its processes relating to how scans were reported and made changes to reduce the risk of findings being overlooked.