Report Date


Case Against

Cardiff and Vale University Health Board



Case Reference Number



Upheld in whole or in part

Ms B complained on behalf of her late mother, Mrs C, about the treatment and care provided at the University Hospital of Wales (“the Hospital”) when she developed difficulty with her breathing and was admitted to the Emergency Department (“ED”). In particular, Ms B said that the Health Board failed to initiate early treatment with non-invasive ventilation (“NIV” – additional breathing support through a tight-fitting mask) and to take any action to remedy identified failings in Mrs C’s care when responding to her complaint.

The investigation found that there were failings during the initial triage and medical assessment which meant that Mrs C’s care was not appropriately prioritised and escalated to a senior doctor for review. Mrs C was very unwell on admission to the Hospital and early treatment with NIV provided the only possibility of reversing her respiratory failure. Sadly, Mrs C was too unwell to benefit from NIV treatment by the time a senior medical review took place and she died later that day. Because of these failings, Ms B has been left with some uncertainty about Mrs C’s outcome which causes her an injustice. Ms B also raised concerns about the impact of sedation and her medical history on the later decision to withhold NIV treatment. These complaints were not upheld.

The Ombudsman recommended that the Health Board should apologise to Ms B and make a redress payment of £1000 in recognition of the failings in Mrs C’s care and the failure to learn and improve from the complaint. The findings should also be shared with the nursing staff in the ED to emphasise the importance of using standardised early warning systems to ensure that the most time-critical patients are prioritised appropriately for medical review.