Report Date


Case Against

Cwm Taf Morgannwg University Health Board


Clinical treatment outside hospital; GP

Case Reference Number



Upheld in whole or in part

Mr A complained that a GP (“the GP”) at the Surgery failed to examine his chest properly, to arrange any investigations for him, to treat his condition, to give him any advice about it or diagnose it correctly on 21 December 2020. Mr A attended a hospital later that day and was subsequently diagnosed as having pulmonary emboli (blocked blood vessels in the lungs) in both lungs and COVID-19 pneumonitis (lungs that have become inflamed because of COVID-19). Mr A also complained that the Surgery’s response to his complaint, about the care that he received on 21 December, was inadequate, inaccurate and unduly delayed.

The Ombudsman found that the GP had assessed and treated Mr A appropriately on 21 December. She did not uphold the clinical care part of Mr A’s complaint. The Ombudsman found that the Surgery’s initial response to Mr A’s complaint was inadequate because it contained significant clinical inaccuracies. She considered that that failing caused Mr A an injustice in the form of uncertainty and distress. She upheld the complaint handling aspect of Mr A’s complaint to a limited extent.

The Ombudsman recommended that the Surgery should review its complaints process to ensure that all relevant clinical information is obtained before it responds to complaints about clinical care. She took into account, when making that recommendation, the action that the Surgery had already taken in response to Mr A’s complaint handling concerns. The Surgery agreed to implement this recommendation.