Report Date


Case Against

A GP Practice in the area of Hywel Dda University Health Board


Clinical treatment outside hospital; GP

Case Reference Number



Upheld in whole or in part

Mr W complained about the care provided to his mother, Mrs Y, by her GP Practice. Specifically, Mr W complained that the Practice missed opportunities to diagnose Mrs Y’s pancreatic cancer.
The Ombudsman’s investigation found that the care provided to Mrs Y on 13 April 2021 fell below expected standards because there was a failure to carry out appropriate clinical assessments. This did not, on balance, cause a delay in diagnosing Mrs Y’s pancreatic cancer and did not affect the course of her illness. However, the investigation found that the inadequate care would have caused additional distress to Mrs Y and her family and may have denied her the opportunity to receive end of life care in her home area. The Ombudsman therefore upheld the complaint.

The Ombudsman recommended that the Practice should apologise to Mr W, share a copy of the investigation report with the GP concerned and complete an action plan to demonstrate that it had taken appropriate actions to learn lessons from the failings identified. The Ombudsman was pleased that the Practice agreed to implement these recommendations.