Report Date


Case Against

Cardiff and Vale University Health Board


Clinical treatment outside hospital; Other

Case Reference Number



Upheld in whole or in part

Mrs A’s complaint related to the care and treatment that she received from Cardiff and Vale University Health Board (“the Health Board”). Specifically, Mrs A complained that the Health Board had failed to diagnose her with a vesico-vaginal fistula (an abnormal opening between the bladder and vagina) in a timely manner. She also complained about the length of time that the Health Board had taken to respond to her formal complaint.

The Ombudsman found that there were missed opportunities in the investigation of Mrs A’s urinary symptoms and that there should have been a stronger suspicion among clinicians of a vesico-vaginal fistula being the cause of these symptoms. The Ombudsman also found that there were delays between clinic appointments and investigations throughout the period under review. As a result, the Ombudsman concluded that there was a failure to diagnose Mrs A’s vesico-vaginal fistula in a timely manner and so upheld this aspect of the complaint. The Ombudsman also upheld Mrs A’s complaint in relation to the Health Board’s handling of her complaint.

The Ombudsman recommended that the Health Board apologise to Mrs A and offer her a payment of £750 in recognition of the distress and frustration caused by the failings identified in the investigation. The Ombudsman also recommended that her investigation report was shared with the relevant clinicians involved in Mrs A’s care for them to reflect on its findings for learning purposes. Finally, the Ombudsman recommended that the investigation report be discussed at the Health Board’s Quality and Safety meeting (or in an alternative appropriate forum) and to consider whether any actions or improvements could be taken forward as a result of that discussion.