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Health board apologies after “significant service failure” led to man’s death

20 Jan 2023 2 minute read
University Hospital of Wales – Photo: Scglossop1 CC BY-SA 4.0

Cardiff and Vale health board has apologised after “inappropriate discharge and missed opportunities to diagnose” led to the death of a patient.

The Public Services Ombudsman launched an investigation after the patient’s daughter complained the hospital didn’t provide appropriate care.

In the complaint, the daughter said the family’s lives were “destroyed” and asked for answers.

After launching an investigation the Ombudsman said the man’s death was “a significant service failure” that could have been avoided.

The damning report found the patient had a “bowel obstruction/strangulated hernia” but Cardiff’s University Hospital of Wales failed to “adequately assess his clinical history and new symptoms” which pointed to an obstructed hernia.


The man, named in the report as Mr Y, attended the hospital’s A&E department but was sent home and the Ombudsman found “further assessment and admission at this time might have changed the outcome for him”.

When Mr Y was readmitted to hospital two days later, the report found there was a delay in diagnosis before he eventually received emergency surgery and Mr Y sadly died after deteriorating further.

The report noted that when Mr Y became very ill, he was not moved to the Intensive Care Unit – a decision the Ombudsman found “reduced his chances of survival.”

Michelle Morris of the Ombudsman said: “I am saddened to conclude that, had these clinical failings not occurred and had the patient received appropriate care following surgery, his deterioration and death, on balance, might have been prevented.”

She added the findings of the report would undoubtedly cause “distress” to the patient’s family.

Cardiff and Vale University Health Board “apologised unreservedly”.

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