Report Date


Case Against

Hywel Dda University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Mrs R complained about the care and treatment provided to her late husband, Mr R, by Hywel Dda University Health Board between May and December 2021. She specifically complained that there were unacceptable delays between a consultation on 4 May, and bowel surgery taking place on 26 July. She complained that Mr R was inappropriately discharged from hospital on 29 November with oral anti-sickness medication, when he was unable to eat and drink. Mrs R complained that there were inappropriate delays in administering medication to Mr R when he attended the Emergency Department on 9 December. Mrs R also complained that, while an inpatient in December, conflicting options between the Oncology and Surgical teams caused frustration and confusion to Mr R and his family, and ultimately led to him being deprived of nutrition for 11 days.

The investigation found that there was a delay in Mr R having bowel surgery and this complaint was upheld. It was found that Mr R had an appropriate assessment and treatment on 29 November and this complaint was not upheld. The investigation also found that there were delays in administering medication to Mr R on 9 December, failings in Mr R’s nutritional assessment and management, and a need for closer collaboration between the professionals involved in his care. These complaints were upheld.

The Health Board agreed to apologise to Mrs R for the failings identified and make a financial redress payment of £1000, and also to share the report with relevant clinicians, remind staff of the importance of close collaboration for complex cases and remind staff of the need to complete nutritional screening at the appropriate time and frequency. It also agreed to arrange for the report to be discussed at an appropriate clinical governance meeting, review its training of staff in relation to nutritional screening and referrals to dietetic services, and provide an update on the implementation of new guidance on malignant bowel obstruction.