Report Date


Case Against

Cardiff and Vale University Health Board



Case Reference Number



Upheld in whole or in part

Mr and Mrs A complained about the care their daughter, Ms B, received from the Health Board. They complained that Ms B’s treatment was delayed: specifically, she was transferred to hospital on 17 March, but her chemotherapy did not begin until 24 March. They also complained that Ms B was not monitored closely enough following the commencement of her chemotherapy, including whether Mrs A’s concerns over the level of Ms B’s blood pressure overnight from 24-25 March were addressed and whether sepsis should have been identified sooner.

The investigation found that the week that passed before Ms B commenced chemotherapy was reasonable owing to the other care and treatment she needed. This complaint was not upheld. The investigation also found that Ms B had experienced several episodes of infection/sepsis and that they had been treated appropriately. However, the monitoring of Ms B following her chemotherapy was not adequate in terms of frequency and escalation, and the appropriate chart for a patient with learning difficulties was not used throughout Ms B’s care. These failures caused an injustice to Ms B and Mr and Mrs A because Ms B’s deterioration was not highlighted, so Mr A was not with Ms B and Mrs A during Ms B’s final hours. This complaint was partly upheld on this basis.

The Ombudsman recommended that the Health Board should provide Mr and Mrs A with a written apology for the failings identified in this report. She also said the Health Board should remind nursing staff of the levels at which care should be escalated and the corresponding frequency of observations. Finally, she recommended nursing staff should be reminded that an appropriate chart should be used for patients with learning difficulties. The Health Board accepted the findings of the investigation and the Ombudsman’s recommendations.