PSOW Individual Decisions

Ms A complained that the Health Board had not followed guidelines in relation to procedures for the treatment of overseas nationals. In particular, she said that the Health Board had not properly considered whether the debt she had incurred for treatment should be written off. The assessment found that the Health Board had not considered the complainant’s ability to pay the debt. The Ombudsman sought and gained the Health Board’s agreement to, within one month, contact the debt collection agency to re-activate the process and for Ms A to be issued with an Income and Expenditure form. Following completion and return of the form, the Health Board would then reach a decision about whether the debt could and should be pursued.

Complaint about care and treatment provided following hysteroscopy and biopsy in March 2023 that showed endometrial atypical hyperplasia. Agreed care plan did not take place and Mrs A was diagnosed with endometrial cancer in July 2024, which resulted in a hysterectomy and removal of ovaries. Mrs A said that the Health Board’s response did not fully address her concerns and did not address qualifying liability. Health Board agreed to provide a response addressing concerns and to comment on qualifying liability. Written apology also to be provided.

Mr A complained that the Health Board did not address all his concerns in its complaint response. At assessment, it was found that the Health Board’s complaint response did not address all of Mr A’s concerns. The Health Board agreed, within 6 weeks of the decision letter, to provide a further response to Mr A that addressed each of the outstanding concerns.

Mr A complained about delays on the part of the Health Board in carrying out knee surgery for a family member. The assessment found that the Health Board’s complaint response could have been more detailed, in particular regarding the cause/s of the delays that had impacted the surgery. The lack of clarity amounted to injustice, given the Health Board’s acknowledgement of the impact of the delay on patient outcome and challenges in service delivery. The Ombudsman sought and gained the Health Board’s agreement to provide a further complaint response, including comment on qualifying liability. The Health Board agreed to do so within one month.

Mrs X complained that Hywel Dda University Health Board failed to respond to the complaint she submitted in March 2024. The Ombudsman found that the Health Board failed to respond to the complaint and the Ombudsman said this caused uncertainty and frustration for Mrs X. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to, within 7 weeks, provide the final complaint response that will include an apology and explanation for the delay, a financial redress offer of£100 in recognition of the delay and the relevant details to arrange a post response meeting. Following the meeting, the Health Board will also provide a summary of the discussion within 2 weeks.

Mrs X complained that Hywel Dda University Health Board failed to respond to the complaint she submitted in April 2024. The Ombudsman found that the Health Board had failed to provide Mrs X with a formal complaint response. The Ombudsman said this caused uncertainty and frustration for Mrs X. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to, within 4 weeks, provide the final complaint response which will also include an apology and explanation for the delays and a financial redress offer of £150 in recognition of the delays.

Miss C complained about a GP Practice in the area of Hywel Dda University Health Board. The complaint subject to investigation was whether, between April and August 2024, the GP Practice arranged clinically appropriate investigations/examinations in response to Miss C’s presenting symptoms and patient history. The Ombudsman’s investigation found that the GP Practice’s overall management and care of Miss C in respect of her knee-related complaints during the time period in question was of an appropriate clinical standard and in line with national guidelines. Accordingly, Miss C’s complaint was not upheld.

Ms X complained that the Surgery failed to provide a response to the complaint she submitted to it in February 2025. The Ombudsman found that the Surgery had failed to keep Ms X updated and it had failed to provide a response. The Ombudsman said this caused uncertainty and frustration for Ms X. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Surgery’s agreement to, within 4 weeks, issues its complaint response, include an apology and explanation for the delay and to offer £100 financial redress in recognition of the delay and lack of updates.

Mr and Mrs A complained to Hywel Dda University Health Board regarding the treatment and care Mr A had received and how they had not had a complaint response. The Ombudsman found that Mr A had complained to the Health Board 10 months ago and had still not received a formal complaint response. The Ombudsman said this caused a number of unanswered questions for both Mr and Mrs A. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman gained the Health Board’s agreement to, within 6 weeks, provide the full complaint response, including an apology and an explanation as to why there was a delay.

Mrs B complained that Hywel Dda University Health Board injected air into her daughter during a routine CT scan. Mrs B was also unhappy with assurances made by the Health Board that were not followed through. The Ombudsman decided that nothing further could be achieved in respect of the treatment. The Health Board had apologised and outlined actions taken in response. Further, there did not appear to have been significant harm caused to Mrs B’s daughter. However, the Ombudsman was concerned that the Health Board had offered a meeting to discuss the complaint response in March 2025 which had still not taken place. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to, within 1 month, apologise to Mrs B for its failure to arrange a meeting and within 2 months, ensure that a meeting takes place, sending a follow-up letter to Mrs B to advise of any further outcomes.

Mrs A complained that the GP Practice had failed to provide appropriate care and treatment in relation to swabs and urine samples. She also had concerns about the safety of the swab that she had used, which had been placed in a charcoal solution, and that it might have been used on a previous patient. Mrs A was also dissatisfied with the GP Practice’s complaint handling and its complaint response. The Ombudsman’s investigation found that there was a missed opportunity to have stopped Mrs A using the swab when she initially contacted the GP Practice querying whether it was safe. The situation caused Mrs A considerable anxiety and for this reason, and to this extent only, this part of Mrs A’s complaint was upheld. The Ombudsman found no evidence that would suggest that the charcoal swab had been used or might have been used prior to Mrs A, nor was there any evidence that the charcoal was unsafe and may therefore have caused Mrs A physical harm. This aspect of Mrs A’s complaint was not upheld. The Ombudsman’s investigation did identify administrative shortcomings amounting to maladministration in the GP Practice’s complaint handling process, especially around record keeping. As a result the investigation process was not as robust as it could have been and this caused Mrs A an injustice. This part of Mrs A’s complaint was upheld. The GP Practice agreed with the Ombudsman’s recommendation that it review its handling of Mrs A’s complaint as a point of learning and that it develop an action plan to address any failings/additional failings identified, which it should share with the Ombudsman’s office.

Mrs X complained that Hywel Dda University Health Board failed to respond to the complaint she submitted approximately 18 months ago. The Ombudsman found that the Health Board failed to provide the formal complaint response. The Ombudsman said this caused uncertainty and frustration for Mrs X. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to, within 30 working days, provide an apology and explanation for the delay, offer a £200 financial redress payment in recognition of the delays and provide the final complaint response.

Mrs C complained about the care and treatment her late mother, Mrs A, received from Swansea Bay University Health Board (“the First Health Board”) between 18 and 22 March 2023. Her concerns include the delay in administering regular medication to Mrs A prior to the Transcatheter Aortic Valve Implantation (“TAVI” – a procedure that improves the blood flow in the heart by replacing an aortic valve) procedure between 18 and 22 March 2023. She questioned whether Mrs A was fit enough to undergo a TAVI procedure on 22 March 2023 and if the TAVI contributed to Mrs A developing pancreatitis (inflammation of the pancreas). Mrs C also complained about the care and treatment Mrs A received from Hywel Dda University Health Board (“the Second Health Board”) and whether there was a missed opportunity to treat Mrs A for sepsis (a serious life-threatening reaction to an infection) during her hospital admission between 28 April 2023 and 6 May 2023. The Ombudsman’s investigation in relation to the First Health Board found that, whilst there was a delay in administering medication to Mrs A, she was appropriately medicated and any delays did not materially affect her care. The investigation also found that Mrs A was fit enough to undergo the TAVI procedure and that there was no causal link between the TAVI procedure and the development of Mrs A’s pancreatitis. Mrs C’s complaint was not upheld. With regard to the Second Health Board, the investigation found that there was no evidence of a missed opportunity to treat Mrs A for sepsis between 28 April and 6 May 2023. The Ombudsman did not uphold this complaint.

Ms A, on behalf of 7 complainants, complained that Hywel Dda University Health Board had stopped providing an appropriate specialist service to epilepsy patients who had a learning disability (“LD”). All 7 complainants had adult children who had been using the service. They said that the Health Board failed to make adequate provision for their care after the service had ended in June 2021, and that there was still no adequate plan in place to meet the needs of LD epilepsy patients within the Health Board. The investigation found that when the Health Board’s LD Epilepsy Service ceased in June 2021, the Health Board did not review the patients on its lists in a timely manner, nor did it provide adequate alternative provision to meet their needs. The Ombudsman also found that, 4 years later, there was still no appropriate and accessible pathway in place to ensure that the needs of this group of patients was adequately met. The Ombudsman upheld the complaint. The Ombudsman was concerned that the shortcomings identified affected a very vulnerable group of patients. An appropriate service was still not in place and this potentially affected more than the 7 complainants who approached the Ombudsman’s office. The Ombudsman made a number of recommendations, which the Health Board accepted. a) Take immediate steps to progress its plans to implement a clear and accessible LD Epilepsy care pathway, in line with the External Review findings, so that all patients within its area can access care and support appropriate to their needs. It should obtain an external professional clinical review to ensure the adequacy of the pathway and proposed provisions. It should update the Ombudsman about the action it has taken within 4 months of the date of this report. b) Ensure that there are timescales attached to any action plan and that there is Board oversight of progress, in line with the stated timescales. Within 2 months: c) For each of the 7 complainants, provide a written apology for

Mrs C complained about the care and treatment her late mother, Mrs A, received from Swansea Bay University Health Board (“the First Health Board”) between 18 and 22 March 2023. Her concerns include the delay in administering regular medication to Mrs A prior to the Transcatheter Aortic Valve Implantation (“TAVI” – a procedure that improves the blood flow in the heart by replacing an aortic valve) procedure between 18 and 22 March 2023. She questioned whether Mrs A was fit enough to undergo a TAVI procedure on 22 March 2023 and if the TAVI contributed to Mrs A developing pancreatitis (inflammation of the pancreas). Mrs C also complained about the care and treatment Mrs A received from Hywel Dda University Health Board (“the Second Health Board”) and whether there was a missed opportunity to treat Mrs A for sepsis (a serious life-threatening reaction to an infection) during her hospital admission between 28 April 2023 and 6 May 2023. The Ombudsman’s investigation in relation to the First Health Board found that, whilst there was a delay in administering medication to Mrs A, she was appropriately medicated and any delays did not materially affect her care. The investigation also found that Mrs A was fit enough to undergo the TAVI procedure and that there was no causal link between the TAVI procedure and the development of Mrs A’s pancreatitis. Mrs C’s complaint was not upheld. With regard to the Second Health Board, the investigation found that there was no evidence of a missed opportunity to treat Mrs A for sepsis between 28 April and 6 May 2023. The Ombudsman did not uphold this complaint.

Mr P complained that Hywel Dda University Health Board (“the Health Board”) failed to provide appropriate treatment for a basal cell carcinoma under his right eye (“the BCC”). He also complained that following a surgical procedure on the BCC in February 2023, the Health Board failed to make appropriate and timely referrals for further investigation and treatment. The investigation found that the treatment provided in relation to the BCC, including the surgical procedure in February 2023, was appropriate. It was noted that the procedure led to distressing symptoms which resulted from a known complication which can occur and persist following the kind of procedure Mr P underwent. The investigation also found that the Health Board’s clinicians made timely referrals for further care when appropriate. Accordingly, the complaints were not upheld.

Mrs C complained about the care and treatment her late father, Mr A, received from Hywel Dda University Health Board. Specifically, the investigation considered whether there were any unnecessary delays in Mr A’s cancer treatment, whether a Do Not Attempt Cardiopulmonary Resuscitation (“DNACPR”) form was completed against Mr A’s wishes and contrary to national guidance and whether the nursing care Mr A received at the end of his life fell below the required standard. The investigation found that whilst there were unnecessary delays in Mr A’s cancer treatment, these delays would not have significantly affected or impacted the long-term outlook for Mr A. Although this complaint was not upheld, the Health Board was invited to consider the delays and how improvements could be made. The investigation also found that the documentation regarding the DNACPR was incomplete, so it was difficult to ascertain if the decision regarding the DNACPR during Mr A’s final illness was made with his full knowledge and consent. This uncertainty was an injustice to Mrs C, and this part of the complaint was upheld. In relation to the nursing care provided to Mr A at the end of his life, it was determined that this did not meet the required standard. Although the Health Board created an action plan to address the deficiencies identified when it responded to Mrs C’s complaint, there was no learning or commitment from the Health Board around preparing patients with progressive or terminal illnesses, and their relatives, for death. Therefore, this part of the complaint was upheld. The Ombudsman recommended that Mrs C should receive an apology for the failings identified. In addition, it was recommended that the Health Board carry out a number of tasks including sharing the report with nursing staff involved in Mr A’s care, reminding staff of national guidance and to carry out an audit of DNACPR conversations to ensure they fulfilled national guidance.

Mr A complained about the care and treatment provided by a GP Practice, managed by the Health Board. The Ombudsman found that the Health Board had adequately investigated and responded to Mr A’s complaints about prescriptions, appointment requests, medication reviews and communication. However, the Health Board had not investigated his complaint about abnormal blood test results. The response provided by the GP Practice was brief and did not address the concerns Mr A had raised. This had inconvenienced Mr A and caused him distress and frustration. The Ombudsman decided to settle the complaint without investigation. The Health Board agreed to, within 6 weeks, investigate Mr A’s concerns in relation to the abnormal blood test results, provide him with a formal complaint response, and provide a written apology for the failure to investigate his complaint.

Mr A complained, on behalf of Mrs B, that Hywel Dda University Health Board (“the Health Board”) had failed to follow the correct process when considering her appeal against its decision that she was not eligible for NHS Continuing Healthcare funding. Specifically, he complained that the Health Board had determined the appeal before the full written reasons for appeal had been submitted. The Ombudsman found that the Health Board had failed to follow the “Continuing NHS Healthcare – The National Framework for Implementation in Wales” when it determined the appeal without firstly allowing the submission of the full written reasons for appeal. This amounted to maladministration which caused an injustice. The Ombudsman also found that the Health Board’s local policy was not consistent with the National Framework in respect of this issue. Instead of investigating the complaint, the Ombudsman obtained the Health Board’s agreement to allow the full reasons for appeal to be submitted before then determining the appeal. It also agreed to amend its policy to ensure it was consistent with the provisions of the National Framework. It agreed to undertake these steps within 6 months.

Mr G complained that Hywel Dda University Health Board has not responded to a complaint he submitted in June 2024, concerning the care and treatment of his late mother. The Ombudsman found there had been a significant delay with the Health Board to respond to the complaint. This caused additional frustration and uncertainty for Mr G. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to, within 30 working days, issue its complaint response. The response will include an apology and reason for the delay as well as an offer of £150.

Miss X complained about Hywel Dda University Health Board’s handling of the complaint she made to it in October 2024 regarding the care and treatment provided to her late father. The Ombudsman found that there had been a delay in the Health Board responding to Miss X’s complaint which caused frustration to her. The Ombudsman decided to settle the complaint without a formal investigation. The Ombudsman sought and gained the Health Board’s agreement to apologise and explain the reasons for the delay, to offer a redress payment of £150, and to issue the complaint response within 8 weeks.

Ms X complained that Hywel Dda University Health Board had failed to respond to the complaint she had made to it in May 2024. The Ombudsman found that, although the Health Board had been updating Ms X, some of the updates had been prompted by her, and there had been an unreasonable delay in responding to the complaint. The Ombudsman said this caused frustration to Ms X and decided to settle the complaint without a formal investigation. The Ombudsman sought and gained the Health Board’s agreement to apologise and explain the reasons for the delay, offer a £150 redress payment, and to issue the complaint response within 6 weeks.

Ms A complained because she was unhappy with the actions of Hywel Dda University Health Board’s Community and Drug Alcohol Team (‘CDAT’). The Ombudsman decided that the Health Board’s complaint response was reasonable in respect of several of Ms A’s concerns. However, it was noted CDAT had informed Ms A that a meeting with her would be the best course of action to discuss further concerns raised in email correspondence. The meeting was not arranged within a reasonable timeframe. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to, within 2 weeks, provide Ms A with an apology for the meeting not being arranged sooner and to inform her of the Health Board’s intention to investigate and respond to her further concerns, letting her know which concerns will be investigated.

Mr A complained to this office that the GP Practice had failed to address his concerns about the way he had been treated by it. Mr A had previously complained to the GP Practice in December 2024, via his Llais Advocate, but the GP Practice had not responded in writing to his complaint. The Ombudsman found that the GP Practice had failed to investigate and respond to Mr A’s complaint as it should have, under the Putting Things Right Arrangements. Instead of investigating this complaint, the Ombudsman sought and gained the GP Practice’s agreement to investigate and respond to Mr A’s complaint, in accordance with the Putting Things Arrangements, and to apologise to him for not having done so in the first instance. The GP Practice agreed to do this within 30 working days.

Miss E complained that Hywel Dda University Health Board failed to respond to a complaint she submitted in August 2024. The Ombudsman found there was a significant delay with the Health Board issuing its response. This caused additional frustration and uncertainty for Miss E. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to issue the response within 6 weeks. It should include an apology and explanation for the delay and a £150financial redress payment in recognition of the delays.