A PATIENT'S death could have been avoided if a health board had diagnosed a man's hernia issues correctly, according to a damning report by the Public Services Ombudsman for Wales.

Cardiff and Vale Health Board failed to adequately assess a patient’s clinical history and symptoms and did not admit him to the ITU after surgery which ultimately led to his deterioration and death, according to a public interest report.

Mr Y, as the report calls the patient, had a “bowel obstruction/strangulated hernia” that medics missed in what the Ombudsman called “a significant service failure”.

Commenting on the report, Michelle Morris of the Ombudsman, said the man’s family’s lives had been destroyed and they still did not have answers.

“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,” said Ms Morris.

Suzanne Rankin, chief executive for Cardiff and Vale University Health Board, who apologised to the family, said it was not cast iron that the outcome of the case could have been changed. 

“It is always difficult when we cannot say with certainty if the sad outcome could have been different," said Ms Rankin. 

"It is evident that there were missed opportunities identified in the report. We are implementing the recommendations from the Ombudsman.

"We would welcome the opportunity to meet with the family of Mr Y to discuss the report and recommendations in more detail.”

Ms Morris went on the describe the family's anguish.

“When complaining to us, Miss X told us that the family’s lives had been destroyed and they still did not have answers," added Ms Morris.

"I have no doubt that the findings of this report will be a source of great distress to her and her family.”

Ombudsman reports failings at University Hospital of Wales

The Ombudsman launched an investigation after a woman, referred to only as Miss X, complained about the care and treatment that her late father, received at University Hospital of Wales in March 2020. 

Her father, Mr Y, went to the Emergency Department with symptoms of obstructed hernia and bowel obstruction. However, he was discharged without being adequately assessed.

Two days later, he was admitted to hospital, but sadly died a few days later after emergency surgery.

The Ombudsman found that when Mr Y was first admitted the health board did not adequately consider his clinical history and new symptoms. All these symptoms pointed to an acute obstructed hernia which needed treatment – yet the patient was discharged.

When he was admitted to hospital two days later, his condition was not promptly diagnosed, which led to a delay in an emergency surgery. And, although he was very unwell following the surgery, he was not moved to the Intensive Care Unit, which could have increased his chances of survival. Had these failings not occurred, the outcome might have been different, recorded the Ombudsman.

The Ombudsman recommended that CVUHB should provide a written apology to Miss X for the failings identified in her report.

In addition, they recommended that the Health Board should review with relevant staff how hernias are assessed and diagnosed and produce an action plan based on the outcomes, a share the Ombudsman’s report with the clinical director responsible for the relevant clinicians involved in Mr Y’s care, and make sure that they reflect upon and directly discuss its findings.