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 care and treatment that the Health Board provided or commissioned for his wife, Mrs A. The Ombudsman considered Mr A’s complaints that the Health Board failed to:

a) arrange appropriate investigations and treatment for Mrs A’s cancer
b) take appropriate action to investigate and treat a suspected blocked biliary stent (a hollow tube which is inserted to hold open the bile duct, a structure which carries the digestive fluid, bile)
c) appropriately investigate and treat vomiting following Mrs A’s attendance at Glangwili Hospital on 10 August 2020 and her subsequent admission.
d) appropriately manage Mrs A’s risk of blood clots prior to her cardiac arrest on 24 September 2020.

Complaint a) was not upheld. The Ombudsman’s investigation found that the investigations and treatment arranged following Mrs A’s cancer diagnosis were appropriate, taking into account the impact of the COVID-19 pandemic. Complaint b) was upheld. The investigation found that there was a failure in March 2020 to arrange appropriate investigations and a review to confirm or exclude a blocked biliary stent. As a result, Mrs A was deprived of the opportunity for appropriate investigations which potentially could have identified the problem sooner and given her a better chance of avoiding an infection. Complaint c) was upheld. The investigation found that Mrs A had been given an inappropriately high dose of pain-relieving medication, and that the management of her vomiting was avoidably made more difficult by this error. Finally, the investigation found that Mrs A’s risk of blood clots had been managed appropriately before her cardiac arrest. However, complaint d) was upheld to the limited extent that the unavailability of relevant clinical records had caused avoidable distress to Mr A.

The Ombudsman recommended that the Health Board should acknowledge the specific failings identified in the report, apologise to Mr A and make a payment of £500 to him with respect to the injustice relating to the impact of the inappropriate dose of pain-relieving medication. The Ombudsman also recommended that the Health Board should arrange for failures relating to the potential blocked stent and the pain-relieving medication to be discussed at relevant clinical governance meetings.