Clinical treatment outside hospital; GP: A GP Practice in the area of Cardiff & Vale University Health Board Report Date 21/05/2026 Case Against A GP Practice in the area of Cardiff & Vale University Health Board Subject Clinical treatment outside hospital; GP Case Reference Number 202501802 Outcome Upheld in whole or in part The Ombudsman investigated Mrs A’s complaints that the GP Practice: a) failed to diagnose and treat hypertension (high blood pressure) between 2017 and 2021 b) failed to appropriately interpret and act upon the results of an ECG (electrocardiogram – a test that records the electrical activity of your heart, including the rate and rhythm) on 2 March 2017 c) failed to take appropriate action in response to an emergency department referral in July 2020 regarding an X-ray report.
The investigation found that the actions taken by the Practice in relation to the assessment and management of Mr A’s blood pressure fell within the range of acceptable care. Accordingly, this complaint was not upheld. The GP Practice could have arranged to take more blood pressure readings during the period under investigation and could have done more to document and consider the significance of high readings alongside readings recorded at home. There was also a missed opportunity to fully consider differences in the readings between Mr A’s arms. However, these shortcomings were not so serious that the care could be regarded as substandard. Instead, the GP Practice was invited to carry out a further review of Mr A’s care to reflect on these learning points.
The investigation found that it was within the range of acceptable care to interpret the ECG in 2017 as normal and not to arrange further investigations or a specialist referral. This complaint was not upheld.
The investigation found that there was a failure to arrange a clinical review of the emergency department referral and attached X-ray report in July 2020. This administrative failing amounted to maladministration, albeit it was noted that the timing, a matter of months into the COVID-19 pandemic, was a significant mitigating factor. This complaint was upheld.
The GP practice agreed to the Ombudsman’s recommendations to issue a further apology to Mrs A and to make a payment of £750 to her in respect of the injustices identified in the report.