Report Date


Case Against

A GP Practice in the area of Swansea Bay University Health Board


Clinical treatment outside hospital; GP

Case Reference Number



Not Upheld

The Ombudsman investigated a complaint from Mr Y about the way that a trainee GP at the Practice had managed the care of his late wife, Mrs Y, when she had contacted the Practice complaining of a history of 10 days constipation and abdominal pain. A telephone appointment was arranged with the trainee GP who was of the opinion that Mrs Y was suffering from constipation as a result of low fluid intake. He did not arrange to see Mrs Y but told her that if she displayed any “red flag” symptoms she should attend the Emergency Department. 4 days later Mrs Y was admitted to hospital and underwent investigations which identified that she had a bowel perforation in 2 places. Sadly, despite undergoing surgery, Mrs Y died2 days later multi-organ failure, sepsis and perforated colon.

The Ombudsman found that there was a failure to take clinically appropriate action and to arrange a face-to-face consultation with Mrs Y, based on the symptoms she presented with during the telephone consultation on 19 July 2021. It was considered, that on balance, a more thorough assessment or clinical examination may have changed the diagnosis of constipation or may have led to a consideration that Mrs Y was suffering from a more serious underlying cause for the constipation, that needed further investigation.

The Ombudsman upheld the complaint and recommended that the Practice apologise to Mr Y as it was responsible for the service being delivered to their patients. The Ombudsman did not identify an issue with the manner the trainee GP was being supervised. The Ombudsman would have made a number of recommendations to ensure that the trainee GP reflected and learned from this event to ensure the same shortcomings did not happen again. However, since Health Education and Improvement Wales had already ensured that all relevant actions had been undertaken as part of its usual processes, the Ombudsman was satisfied that no further recommendations were required to ensure future learning and improvements.