Report Date


Case Against

Cardiff and Vale University Health Board


Clinical treatment outside hospital; GP

Case Reference Number



Upheld in whole or in part

Mrs A complained about an out of hours GP (“OOHGP”) consultation that took place on 29 February 2020 at the residential placement (“the Placement”) where her son, B, who has a learning disability, autism, epilepsy and attention deficit hyperactivity disorder lived. In particular, she complained about:
• The OOHGP’s conclusion that her son’s pain was not likely to be appendicitis.
• Reasonable adjustments by the OOHGP and the Out of Hours Service especially in relation to communication and pain management.
• Complaint handling.
The following day her son was admitted to hospital and diagnosed and treated for appendicitis.
The Ombudsman’s investigation found, after careful consideration of the evidence, that the OOHGP’s documented conclusion that B had a diarrhoeal illness was a plausible diagnosis based on B’s clinical presentation at the time and that the OOHGP had carried out an adequate assessment of B. The Ombudsman, regarding the disputed evidence about what was discussed by way of safety netting/worsening advice, found that even if the OOHGP did not provide the safety netting advice that he recorded that he had, this did not affect the subsequent course of events, as the Placement had acted correctly and sought appropriate medical assistance the following day. The Ombudsman, whilst not wishing to minimise the significant distress these events must have caused to B and his parents, nevertheless concluded that in terms of the consultation the OOHGP’s actions were not unreasonable and would not amount to service failings based on the Ombudsman’s clinical standards. The Ombudsman did not uphold this part of Mrs A’s complaint.

On the issue of reasonable adjustments, the Ombudsman, while acknowledging Mrs A’s point of view and her concerns that she was not listened to, on balance, after taking the evidence as a whole, concluded that the adjustments the OOHGP made in terms of discussing B with his carers and Mr and Mrs A were sufficient. She did not uphold this part of Mrs A’s complaint.
On complaint handling the Ombudsman did find that there was a delay in providing the OOHGP consultation record to Mrs A in advance of a virtual local resolution meeting with the Health Board. This delay meant that Mrs A was not able to prepare for the meeting with her Advocate as she would have wished and this caused her an injustice. To this very limited extent only, this part of Mrs A’s complaint was upheld.
The Ombudsman recommended that the Health Board apologise in writing to Mrs A for the shortcoming in complaint handling and the delay in providing the OOHGP medical records.