Report Date


Case Against

Cwm Taf Morgannwg University Health Board


Clinical treatment outside hospital

Case Reference Number



Upheld in whole or in part

Mrs A complained that a GP Practice in the area of Cwm Taf Morgannwg University Health Board failed to arrange a timely referral to secondary care for her late mother, Mrs G, between 20 January and 18 March 2020 in relation to increasingly painful symptoms in her lower left leg. Mrs A was later admitted to hospital on 18 March and diagnosed with critical limb ischaemia (an advanced form of peripheral arterial disease, where blood supply to the limb is severely reduced). Sadly, by this stage Mrs G was not fit for surgery and she died the following day. In response to evidence gathered during the investigation, the Ombudsman used his “own initiative” investigation power under Section 4 of the Public Services Ombudsman (Wales) Act 2019 to extend the investigation to consider, as an additional complaint, a concern that between February and March 2020, the Practice’s prescription of antibiotics and diuretics (medications that increase the amount of urine produced) to Mrs G fell outside the range of appropriate clinical practice

In relation to the original complaint, the investigation found that the Practice failed to carry out appropriate investigations into Mrs G’s leg pain which would have been likely to have resulted in an earlier diagnosis of critical limb ischaemia and a referral to a vascular specialist before 4 March. The investigation found that, on balance, Mrs G would have been fit for surgery if she had been referred to a vascular specialist by 4 March. On balance, surgery would have saved her life and may also have saved her leg. The Ombudsman found that the injustice suffered by Mrs G and her family could not have been more serious. Accordingly, the Ombudsman upheld this complaint. The investigation also found that the Practice’s prescription of antibiotics and diuretics to Mrs G fell outside the range of appropriate clinical practice. This was an injustice because, apart from potentially making Mrs G feel unwell, the prescription of diuretics in particular, and the lack of appropriate monitoring, may have contributed to her developing acute kidney injury and low sodium levels. The investigation found that these problems may have contributed to the decision that Mrs G was not fit for surgery. The Ombudsman therefore upheld this complaint.

The Ombudsman recommended that the Practice should apologise to Mrs A and make a payment to her of £2,000 in respect of the injustices caused to her and Mrs G by the failings identified by the investigation. He also recommended that the Practice should, within 3 months, arrange a Significant Event Analysis meeting to examine how the failings identified occurred, and to identify clear learning points to prevent them happening again. The Ombudsman noted that the GP who had provided care to Mrs G had retired, but recommended that the Practice should ask him to agree to tell the Ombudsman (and take other actions relating to his ongoing professional development) in the event that he decided to return to clinical practice.