PSOW Individual Decisions

Mr X complained that Hywel Dda University Health Board had failed to respond to the complaint made by his Member of the Senedd (‘MS’) on his behalf. The Ombudsman found, that although the Health Board had updated Mr X’s MS, it had not updated Mr X or provided a complaint response to him. The Ombudsman said this caused frustration to Mr X and decided to settle the complaint without a formal investigation. The Ombudsman sought and gained the Health Board’s agreement to apologise to Mr X and provide him with an update within 2 weeks, and to issue its complaint response to him within 8 weeks.

Mr A complained that a GP Practice in the area of Hywel Dda University Health Board (‘the Practice’) failed to respond to his request for a pre-booked appointment via letter, resulting in a delay in care and treatment. Mr A said that the Practice’s actions were contrary to information on its website, and that its decisions in relation to his requests were wrong. The Ombudsman decided that the Practice did not establish why Mr A was requesting pre-bookable appointments, and it declined his request without this information. The Practice had not clearly explained the reason for its decision, and this caused Mr A frustration because it appeared to be contrary to the information on the Practice’s website, ultimately resulting in a breakdown in the professional relationship. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Practice’s agreement within 2 weeks, to apologise to Mr A that it did not establish the reason for his request and for making a decision without this information, to apologise that it did not provide a clear explanation for its decision, and how it appeared to be contrary to the information on its website. The Practice also agreed within 1 month, to review its procedures relating to patient requests for adjustments to ensure all options are explored, and clear reasons are recorded and communicated to the patient, and to ask the Health Board’s Primary Care and Equality, Diversity and Inclusion Team to consider the Practice’s approach to pre-bookable appointments to ensure it is appropriately addressing patients’ needs and accessibility.

Dr. A complained that Hywel Dda University Health Board (‘the Health Board’) failed to adequately investigate her complaint about the maternity care that she received. Dr. A felt that her concerns had not been taken seriously and that opportunities to ensure that other women did not have a similar negative experience, were lost. The Ombudsman decided that there had been a significant delay in the Health Board’s consideration of Dr. A’s complaint. This impacted on the quality of the investigation and resulted in missed opportunities for learning and service improvement. The delays in addressing Dr. A’s complaint caused an injustice to Dr. A, which were only partially remedied by the subsequent actions of the Health Board. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to give further consideration to the content of its education and learning programme, review its complaints procedures and write to Dr. A within 3 months to update her on the actions taken as a result of her complaint.

Mr A complained about access to an appointment at a GP Practice in the Hywel Dda University Health Board area. He said that he was unable to access an appointment from September to November 2024. Mr A said he had concerns about the ongoing care and treatment accessible to him and about the response he had received from the Practice when he made a complaint about this matter. The Ombudsman found that, although the Practice had provided responses to Mr A, these did not meet expected standards set out in the Putting Things Right arrangements, and he remained unclear as to some aspects of the care and treatment available to him. The Ombudsman considered that Mr A had not had a full response to his complaint and contacted the Practice, which agreed to undertake the following actions to resolve the complaint and as an alternative to a formal investigation. The Ombudsman sought and gained the Practice’s agreement to, within 4 weeks, in line with the Putting Things Right arrangements, investigate and respond fully to the concerns Mr A raised in his complaint about the Practice.

Mr C complained that Hywel Dda University Health Board had failed to respond to the complaint he submitted in December 2024. The Ombudsman found that the Health Board had yet to provide Mr C with a complaint response which caused additional frustration and uncertainty for him. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to provide Mr C with a final complaint response, which will include an apology and explanation for the delay within 1 week.

Mr C complained that Hywel Dda University Health Board (“the Health Board”) did not forward a referral to a specialist consultant following an appointment, which resulted in him waiting an additional 21 months for an assessment. The Ombudsman decided that the Health Board had acted promptly to correct the error when Mr C raised the issue, but they had not responded to his request for financial redress. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to apologise to Mr C for not considering his request for financial redress and offer him a payment of £700 in recognition of the delay in processing the referral.

Mr A complained that Hywel Dda University Health Board (“the Health Board”) did not report the result of an urgent suspected cancer scan within the timescales set out in national guidelines, which prevented his partner from receiving the palliative care and pain relief he needed. Mr A further complained that the Health Board’s responses to his complaints were delayed and did not adequately address his concerns. The Ombudsman decided that although the information the Health Board provided in response to her enquiries addressed Mr A’s concerns about his partner’s care, the Health Board had not handled Mr A’s complaints in accordance with the NHS Wales complaints regulations. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to review its complaints handling processes and write to Mr A within 3 months to apologise and inform him of the action being taken to improve complaints handling.

Ms A complained about the care and treatment provided to her late grandfather, Mr B, by the Health Board. Ms A was not given information regarding a biopsy undertaken during the first few days of admission, and not informed of Mr B’s cancer diagnosis until he was discharged from hospital. Ms A was concerned he was kept nil by mouth, not given medication and was not moved out of bed during the latter stages of the admission. Ms A was dissatisfied with the Health Board’s response to her complaint. The Ombudsman found that the Health Board’s initial investigation had not fully, or adequately, considered all clinical records. Although a further response was provided, it did not fully resolve matters for Ms A, and the information provided raised further questions. The Health Board agreed within 6 weeks to consider Ms A’s request for an in-depth medical review and the direct questions about Mr B’s tumour and provide a complaint response under the Putting Things Right process.

Ms C complained about the care and treatment she received from Hywel Dda University Health Board (“the Health Board”) when she was in the early stages of pregnancy. She complained that, if an earlier scan had been carried out, she would have known about the ectopic pregnancy at an earlier point and been able to have medical treatment, rather than surgical intervention. The fact that surgery was needed meant that her remaining fallopian tube had to be removed. The investigation considered whether, given Ms C’s presentation and history of ectopic pregnancies, the following decisions were clinically appropriate: • Not to carry out an ultrasound scan when she presented at the Emergency Department (ED). • Not to refer her to the Early Pregnancy Assessment Unit (EPAU) within 24 hours or sooner, following review by the midwife. The investigation found that that the decision not to carry out a scan when Ms C presented at the ED on 29 April was clinically appropriate, given that there was no clinical indication for an urgent ultrasound at that time. The investigation also found that although Ms C should have been offered an earlier scan appointment at the EPAU, it would not have changed the treatment options available to her. The Ombudsman did not uphold Ms C’s complaints.

Mrs B questioned whether Mr B received adequate care and treatment from the Health Board in respect of his admission to hospital between 3 and 30 September 2022. Specifically, she queried whether there was a delay in an oncology review. The investigation found that there was a delay in Mr B’s oncology review, caused by a delayed biopsy of his abnormal tissue. This failure was amplified by miscommunication regarding a review date and a scale used to measure the functional status of cancer patients was miscalculated, which made Mr B’s treatment pathway less clear than it might have been. The complaint was upheld. The Health Board agreed to the Ombudsman’s recommendations to apologise to Mrs B and her family, to review its approach to carrying out biopsies on patients with Urgent Suspected Cancer and to identify learning points to be shared with all relevant staff. The Health Board also agreed to provide refresher training to relevant staff on a tool to measure a patient’s functional status and ability to perform daily activities.

Ms L complained that Hywel Dda University Health Board had failed to respond to the complaint she made to it in March 2024. The Ombudsman found that there was a significant delay in the Health Board issuing its complaint response to Ms L, causing her frustration. 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, issue its complaint response, and offer £150 redress payment to Ms L within 6 weeks.

Mrs A complained about Hywel Dda University Health Board (“the Health Board’s”) failure to provide her mother with timely Ophthalmology clinic appointments to treat her age-related eye disease. The Ombudsman noted that whilst the Health Board in its complaint response had provided an explanation about the timing of appointments and also referred to national guidance in this area, it had not clarified the clinical pathway and contact details to be followed by Mrs A’s mother should her eye health deteriorate. The Health Board agreed to write to Mrs A’s mother about this. It also agreed to apologise to both Mrs A and her mother that this had not been made clear previously.

Mrs A complained about care and treatment provided to her son, B, by Hywel Dda University Health Board. The investigation considered the concern that B’s prescription of isotretinoin (a medicine used to treat severe acne) was not managed appropriately between September 2022 and January 2023. The Ombudsman found that the decision to increase B’s dosage of isotretinoin following a nurse-led virtual appointment on 8 November 2022 was not appropriate as there was evidence that his acne had progressively worsened. At the same appointment there was a failure to identify the need for B to be seen urgently face-to-face. The Ombudsman found, on a balance of probabilities, that earlier review and treatment could have limited the deterioration of B’s acne and associated scarring. Mrs A’s complaint was therefore upheld. The Health Board agreed to the Ombudsman’s recommendations, including to apologise to Mrs A and B and make a payment of £1000 to B to reflect the missed opportunity to limit the extent of skin damage he developed. It also agreed to arrange for the Ombudsman’s report to be shared with the clinical director responsible for the dermatology service and discussed at a relevant clinical governance meeting.

Mrs B complained that Hywel Dda University Health Board had failed to respond to the complaint she submitted in May 2024. The Ombudsman found that there had been a significant delay by the Health Board to provide Mrs B with a response. She said this had caused frustration and uncertainty for Mrs B. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to provide Mrs B with a written apology, to include an explanation for the delay, £150 redress and to issue a complaint response within 6 weeks.

Mrs X complained that Hywel Dda University Health Board failed to provide regular monitoring of her ophthalmic condition. Mrs X also complained that the Health Board had not responded to her letter to the Consultant and found the follow-up responses to her email to be inadequate. The Ombudsman found that the Health Board failed to respond to Mrs X’s correspondence or formally investigate her concerns. 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 3 weeks, write to Mrs X with an apology and an explanation for the oversight in not logging her concerns as a formal complaint. The Health Board also agreed to contact Mrs X to establish the scope of her complaint and conduct an investigation into her concerns under the PTR procedure.

Mr A complained that Hywel University Health Board failed to issue a response to a complaint, which was made to it in December 2022, regarding the care and treatment provided to his mother-in-law. The Ombudsman decided that the Health Board had failed to log, acknowledge, and respond to the complaint. The Ombudsman also found 2 further complaints relating to care and treatment provided to his mother-in-law had not been responded to by the Health Board. The Ombudsman contacted the Health Board, which agreed to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to issue an apology to Mr A for not logging, acknowledging, or responding to the complaint made to it in December 2022 and to provide written responses to the 2 further concerns relating to the care and treatment provided to his mother-in-law. The Health Board agreed to complete these actions within a month.

Ms B complained, with the help of a Complaints Advocate, about the standard of care provided by the Health Board. The investigation considered whether the care and treatment provided at the Early Pregnancy Assessment Unit (“EPAU”) on 21 March 2023 was clinically appropriate, and whether the subsequent Community Midwife Team (“CMT”) care provided was clinically appropriate. The Ombudsman found that Ms B should have been reviewed by the attending obstetrician when she attended the EPAU on 21 March. Ms B should have been prescribed progesterone (a hormone which can lower the risk of miscarriage in women who experience bleeding in early pregnancy and those who have experienced at least one miscarriage) as hers was a “high risk” pregnancy, in view of her previous late pregnancy loss. Ms B did not receive care from the CMT; when she telephoned on 2 occasions to book in for her care, she was refused an appointment because she was planning to move out of the area. Ms B should have been able to book in for care while she was living in the Health Board area, and was entitled to reassurance and care from midwives at an anxious time in her pregnancy. Ms B should have been referred to a consultant obstetrician, so that she was on the appropriate clinical path for regular assessment and further screening in a more timely manner during the following weeks. In addition, the Health Board was unable to provide records of the telephone calls, which amounted to maladministration. The Ombudsman upheld both parts of the complaint, and made recommendations for an apology, financial redress, a reminder to the CMT concerning the offering of appointments, and a review of CMT record keeping.

Mr A complained about how the Practice dealt with his complaint, how he was de-listed from the Practice, and the clinical treatment he received from the Practice. After assessment, the Ombudsman found that the Practice had not responded to Mr A’s complaints under the Putting Things Right process. The Ombudsman found that this caused inconvenience and frustration to Mr A. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Practice’s agreement to do the following: Within 1 month, the Practice should: • Provide Mr A with a PTR response for the complaints he’s raised.

Mrs A complained that the care and support provided by Hywel Dda University Health Board in respect of her diabetes management in 2023 was inadequate and not in line with the National Institute for Health and Care and Excellence (“NICE”) guidance. The investigation also considered whether the level of respite care provided to her daughter was adequate The investigation found that the care and support provided to Mrs A in relation to her diabetes management in 2023, both in terms of her clinical and social needs exceeded the recommended NICE guidance. The Ombudsman also found that the level of respite care provided to Mrs A’s daughter was appropriate. Mrs A’s complaint was not upheld.

Mrs A complained about care provided to her by Hywel Dda University Health Board (“the First Health Board”) and Swansea Bay University Health Board (“the Second Health Board”). The Ombudsman investigated the following specific concerns: a) That the First Health Board failed to liaise appropriately with the Wales Fertility Institute (“the WFI” – which is operated at Neath Port Talbot Hospital by the Second Health Board) to ensure that Mrs A received appropriate fertility care. b) That the First Health Board failed to explain the potential impact of Mrs A’s hydrosalpinx (where a fallopian tube becomes blocked, which can lead to fertility problems) to Mrs A or her GP in a timely manner. c) That before providing cycles of in vitro fertilisation (“IVF” – where an egg is removed from the woman’s ovaries and fertilised with sperm in a laboratory) treatment to Mrs A in 2016 and 2020 the Second Health Board failed to carry out appropriate additional screening, taking into account her medical history. The Ombudsman found that the First Health Board missed opportunities in 2016 and 2018 to inform the WFI about Mrs A’s history of hydrosalpinx. This was caused by a series of communication failures, and an apparent failure to consider the significance of the condition. The First Health Board failed to offer Mrs A surgery to treat the condition and improve her chances of conceiving through IVF. As a result of this, the IVF treatment Mrs A received was compromised. The First Health Board also failed to explain the significance and potential impact of the hydrosalpinx to Mrs A or her GP. Complaints a) and b) were upheld. The Ombudsman found the Second Health Board, through the WFI, failed to request a copy of a scan report mentioned in the 2016 IVF referral. This was a missed opportunity to ensure that Mrs A’s history of hydrosalpinx was considered and addressed prior to starting IVF. Complaint c) was also upheld. As a result of the failings identified, the IVF treatment Mrs A under

Mrs A complained about care provided to her by Hywel Dda University Health Board (“the First Health Board”) and Swansea Bay University Health Board (“the Second Health Board”). The Ombudsman investigated the following specific concerns: a) That the First Health Board failed to liaise appropriately with the Wales Fertility Institute (“the WFI” – which is operated at Neath Port Talbot Hospital by the Second Health Board) to ensure that Mrs A received appropriate fertility care. b) That the First Health Board failed to explain the potential impact of Mrs A’s hydrosalpinx (where a fallopian tube becomes blocked, which can lead to fertility problems) to Mrs A or her GP in a timely manner. c) That before providing cycles of in vitro fertilisation (“IVF” – where an egg is removed from the woman’s ovaries and fertilised with sperm in a laboratory) treatment to Mrs A in 2016 and 2020 the Second Health Board failed to carry out appropriate additional screening, taking into account her medical history. The Ombudsman found that the First Health Board missed opportunities in 2016 and 2018 to inform the WFI about Mrs A’s history of hydrosalpinx. This was caused by a series of communication failures, and an apparent failure to consider the significance of the condition. The First Health Board failed to offer Mrs A surgery to treat the condition and improve her chances of conceiving through IVF. As a result of this, the IVF treatment Mrs A received was compromised. The First Health Board also failed to explain the significance and potential impact of the hydrosalpinx to Mrs A or her GP. Complaints a) and b) were upheld. The Ombudsman found the Second Health Board, through the WFI, failed to request a copy of a scan report mentioned in the 2016 IVF referral. This was a missed opportunity to ensure that Mrs A’s history of hydrosalpinx was considered and addressed prior to starting IVF. Complaint c) was also upheld. As a result of the failings identified, the IVF treatment Mrs A under

Mr A had eye surgery in 2023 and experienced a cataract which is a known complication of the type of procedure that he had. Mr A, who was placed on the urgent waiting list for a cataract operation in March 2024, complained about delays in the operation being carried out. He also expressed concerns about the deterioration in his vision and that it might undo the benefits of his previous eye surgery. The Ombudsman identified that the Health Board in its complaint response to Mr A had not addressed the issue of harm as part of it Putting Things Right (“PTR”) response. Mr A’s position of the waiting list was also unclear as well as who, surgically, was responsible for his cataract management and care. The Health Board agreed to provide Mr A with a further complaint response which addressed the issue of harm. In addition, it agreed to provide a general update on his waiting list position and clarify Mr A’s care pathway. It also said that it would review Mr A’s case and identify steps to ensure PTR requirements around harm are met where this is appropriate.

Ms A complained about the care and treatment provided by Hywel Dda University Health Board’s (“the Health Board”) mental health team to her sister in law. The assessment found that, although there had been a serious incident review, the Health Board had not issued a response under the Putting Things Right complaint regulations (“the Regulations”). The Ombudsman sought and gained the Health Board’s agreement to issue a full response to the complaint, which would comply with the regulations including timescales set out there.

Miss X complained that Hywel Dda University Health Board had failed to respond to her complaint in line with its internal complaint process regarding Miss X being incorrectly told she had a stroke. The Ombudsman concluded that the Council had failed to respond to the complaint in line with its complaint process. The Ombudsman said this caused uncertainty, frustration, and inconvenience to Miss X. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to respond to the complaint, apologise for the delay and inconvenience caused and offer a redress payment of £100 in recognition of the delay and need to approach the Ombudsman, within 30 working days.

Mrs X complained that Hywel Dda University Health Board had failed to respond to the complaint she submitted in March 2024. The Ombudsman decided that there had been a delay by the Health Board to provide Mrs X with a response. She said this had caused frustration and uncertainty for Mrs X. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to apologise to Mrs X and issue a complaint response within 30 working days.