Report Date


Case Against

A Medical Practice in the area of Cwm Taf Morgannwg University Health Board


Clinical treatment outside hospital; GP

Case Reference Number



Upheld in whole or in part

Mr A complained about the treatment given to his mother, Mrs B, by the Practice. He stated that Mrs B had repeatedly raised concerns for 15 months before she was diagnosed with ovarian cancer, and if the Practice had responded appropriately, including offering her face-to-face consultations rather than telephone ones, her cancer may have been diagnosed and treated earlier. He also complained that giving Mrs B her cancer diagnosis over the telephone was inappropriate, and that the Practice’s response to his complaint was insufficient.

The investigation found that while Mrs B had fairly frequent contact with the Practice over the period, she only raised concerns about symptoms that could be linked to ovarian cancer on 2 occasions, and these were treated appropriately. It found the decision by the Practice to only offer face-to-face consultations when medically necessary was in line with guidance issued to GPs as a result of theCOVID-19 pandemic, and concluded that, in Mrs B’s case, face-to-face appointments were not clinically necessary, and there was no evidence they would have resulted in a faster diagnosis. It found that the GP did not give Mrs B a definitive diagnosis over the telephone, but explained that test results suggested that cancer could be one reason for Mrs B’s illness. Given the ongoing COVID-19 restrictions and the need to provide Mrs B with information regarding treatment as soon as possible, the investigation found it was appropriate to provide this information via telephone. These complaints were therefore not upheld. However, the investigation found that the original complaint response provided to Mr A did not go into sufficient detail about Mrs B’s consultations or answer all his concerns. This was an injustice to him and this complaint was therefore upheld.

The Ombudsman recommended that the Practice should:

a) Apologise to Mr A for the failings outlined in the report in relation to complaint handling.

b) Internally review Mr A’s complaint and how it was handled.

c) Liaise with its primary care service provider (the Health Board) to discuss arranging complaints handling training in relation to the quality and production of complaint responses.

The Practice agreed to implement these recommendations