Source · PSOW (Public Services Ombudsman for Wales)

Hywel Dda University Health Board

PSOW (Public Services Ombudsman for Wales) Partly Upheld Reference PSOW-202501044 Sector Health Category Clinical treatment in hospital Decided 24 March 2026

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Full decision

Mrs L complained about the care provided to her late brother, Mr M. We investigated concerns about whether opportunities were missed to make an earlier diagnosis of pulmonary embolism (a blocked blood vessel in the lungs) and whether Mr M’s treatment after diagnosis of a pulmonary embolism was appropriate, timely and in keeping with relevant guidance.

The investigation found that despite Mr M’s presentation giving reason to consider a diagnosis of pulmonary embolism, relevant tests were not conducted. This was a failing and an injustice to Mrs L who will be left with uncertainty regarding what the outcome may have been had these tests been conducted. This part of Mrs L’s complaint was upheld.

Once pulmonary embolism was diagnosed, Mr M’s clinical management was appropriate and treatment was carefully considered and risk assessed in light of his complex condition. This part of Mrs L’s complaint was not upheld.

The Health Board agreed to apologise to Mrs L and offer her financial redress of £750 in recognition of the distress caused by the uncertainty she will be left with. It also agreed to ensure that the clinicians that treated Mr M during his first admission to the Hospital are familiar with the symptoms of pulmonary embolism, particularly in patients with pre-existing lung conditions.

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