PSOW Individual Decisions

Mr H complained that Swansea Bay University Health Board had failed to respond to the complaint made to it in September 2024. The Ombudsman found that there had been a delay in the Health Board responding to Mr H’s complaint, which the Ombudsman said caused him 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 and to issue its complaint response within 6 weeks.

Ms A complained that Swansea Bay University Health Board had failed to respond to the complaint she made to it in October 2024. The Ombudsman found that there had been a delay in the Health Board responding to Ms A’s complaint, causing frustration to Ms A. 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 and to issue its complaint response within 4 weeks.

The complaint related to the standard of care provided to Mr C at the ED at Morriston Hospital following a fall at home which caused a head wound. The Ombudsman’s investigation considered whether Mr C should have had a haemoglobin test, or additional investigations or monitoring, before discharge home. A patient with a head wound with a clear Computerised Tomography (‘CT’ – using computers and images to provide a more detailed image of the body) head scan, and no ongoing bleeding, can be discharged home. However, in Mr C’s case there were additional risk factors due to his age and comorbidities (Mr C had previously been treated for blood cancer (myeloma) as well as a heart attack for which he took anticoagulant medication to help prevent his blood clotting). These required additional consideration and observations which were not evidenced in the clinical records; of particular significance, there was no record that Mr C’s bleeding had stopped, or details of his previous haemoglobin level. Without this information, it was impossible to determine whether it was clinically reasonable to discharge Mr C at that point. However, the absence of any documentation to show that these relevant factors were fully considered before Mr C was discharged was a failing. The Ombudsman upheld the complaint and made several recommendations. The Health Board agreed to apologise to Mr C’s family, and review its ED practices given comments made by the Ombudsman’s Adviser, including the use of a head injury proforma, recording ongoing observations and record keeping.

Mrs A complained about the standard of care provided to her late mother, Mrs B, when she was an inpatient at Morriston Hospital in 2022. She highlighted concerns about nursing care and a delayed diagnosis of Cushing’s syndrome. In its response to the complaint, the Health Board acknowledged that there had been a breach of duty of care in relation to the delayed referral and diagnosis of Cushing’s syndrome. However, the Ombudsman’s view was that it had not given adequate reasons for its conclusion that there was no qualifying liability (harm) in this case, and that the matter should be referred through the statutory redress process. The Health Board therefore agreed to: Within 2 months Refer Mrs A’s complaint back through the statutory redress process(under regulation 26) for assessment of level of harm due to the delayed referrals and diagnosis of Cushing’s syndrome. Provide an additional written response to Mrs A about the learning andimprovement resulting from her complaint.

Mrs X complained that Swansea Bay University Health Board failed to respond to the complaint she submitted in January 2025. The Ombudsman found that there had been delays in responding to Mrs X’s formal complaint. 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 2 weeks, offer an apology for the delay and lack of updates and explain the reasons for this. In addition to also providing the formal complaint response by the agreed date.

Miss A complained that the care and treatment provided to her in December 2023 was not clinically appropriate in view of her presenting symptoms. Miss A also raised concerns about the way the Practice handled her complaint including the timeliness and content of the response. The Ombudsman found that, although clinically appropriate care was provided by the Practice, it had not recorded specific, detailed safety advice given. On this basis, it could not be concluded that appropriate information was provided to Miss A. This was an injustice to Miss A as it may have led to a delay in her seeking further treatment for her later symptoms. In addition, due to the significant delay in responding to Miss A’s complaint, and that the response did not provide an explanation or apology for this, the Ombudsman upheld the complaint about how this was managed by the Practice. The Ombudsman recommended that, within 4 weeks, the Practice provide Miss A with a written meaningful apology for the failings identified regarding the lack of detail recorded about the safety netting advice given as well as for complaint handling. In addition, for the Practice to offer Miss A a redress payment of £250 to reflect the time and trouble with raising her complaint. The Ombudsman also recommended that the Practice shared the case with staff to reflect on the shortcomings identified in relation to the lack of specific and detailed documentation of safety netting advice.

Mrs C complained about the care provided to her husband, Mr C, by Swansea Bay University Health Board (‘the Health Board’) when he was an inpatient at Morriston Hospital. Specifically, whether Mr C’s catheter was appropriately managed between September and December 2022. The Ombudsman found that, although many aspects of Mr C’s catheter care and management were appropriate, there were instances of shortfalls in the documentation, monitoring and management of Mr C’s catheter between September and December 2022 that could have contributed to increasing the risk of urinary tract infections (‘UTIs’). This service failure was an injustice to Mr C. The Ombudsman therefore upheld the complaint. The Health Board agreed to the Ombudsman’s recommendations; to provide a written apology to Mr and Mrs C for the failings identified; to develop and implement a Fluid Balance and Hydration procedure and an audit process to ensure adherence to procedure, if not already available; to implement an audit process of catheter related and fluid balance related annual training, to monitor completion; to develop and implement a catheter valve patient assessment process, to ensure patient competence assessment can be more robustly demonstrated, and; to implement an Internal Safety Alert and targeted education on urinary catheter clamping, to reiterate the Health Board’s Policy.

Ms B complained about the standard of care provided by Swansea Bay University Health Board (‘the Health Board’) between April and June 2023. The investigation considered whether the Health Board took into account her previous pregnancy loss when providing care, whether imaging scans and a cervical stitch procedure were conducted within an appropriate timeframe and whether the care provided to Ms B on 7 June 2023, when it was confirmed she would suffer a pregnancy loss, was appropriate. The Ombudsman found that the Health Board’s records were contradictory about Ms B’s previous pregnancy loss, partly because of errors in the completion of the booking documentation (which, in places, indicated it was Ms B’s first pregnancy). Ms B should have been referred for consultant led care after the booking appointment on 19 April, as hers was a ‘high risk’ pregnancy, but this did not happen until Ms B questioned the delay in doing so, resulting in a delay of some 3 weeks. It was also found that Ms B did not have the appropriate imaging scans at the appropriate time. As well as usual dating scans, she should have had a transvaginal ultrasound scan from 14 weeks. Instead, she had an abdominal ultrasound scan, and only at 16 weeks. If Ms B had had the appropriate imaging scan at the appropriate time, it is likely that the need for a cervical stitch, which was inserted at 16 weeks and 2 days, would have been identified sooner and inserted no later than 15 weeks. It is possible that, if this had been done, Ms B might not have suffered a miscarriage. The uncertainty is an injustice to Ms B. On 7 June Ms B could have been provided with Entonox sooner if she had been transferred to the labour ward earlier, and her cervical stitch would likely have been removed before her baby was delivered. The delay in transferring her and providing Entonox was an injustice to Ms B. All complaint points were upheld. The Health Board agreed to the Ombudsman’s recommendations, including an apology to Ms

Mr B complained that a GP Practice in the Swansea Bay University Health Board area (‘the Practice’) removed his access to a supply of ‘just in case’ antibiotics for his longstanding bilateral bronchiectasis. Mr B had a 7-day supply of antibiotics on repeat prescription but had not had a review of his bronchiectasis or antibiotic use since late 2019. The Practice realised in October 2023 that Mr B had requested 4 issues of antibiotics in the previous 12 months. The Practice Pharmacist attempted to contact Mr B but was unable to. The prescription was therefore altered the prescription so that Mr B could get 1 further prescription with advice that a GP should carry out a review. Mr B made an appointment in December 2023 as he was concerned about his more frequent antibiotic use, which coincided with the Practice wishing to review him. At this appointment the GP referred Mr B to a respiratory consultant for review and their opinion. The GP also removed the ‘just in case’ antibiotics and instead advised Mr B to seek urgent medical help if he felt he required these. The investigation found that the actions of the GP were within the range of appropriate clinical practice, and that the care and treatment provided by the Practice did not amount to service failure which caused a significant injustice or hardship to Mr B. Therefore, the complaint was not upheld.

Ms X complained about the Health Board’s handling of a placement funding request relating to a change in placement for her son. She raised concerns about delays, communication and the way professionals discussed the situation during a meeting. The Ombudsman found that Ms X had not received an adequate response to her complaint, which did not address matters in sufficient detail. Although a further response was provided by the Health Board following a meeting in January 2025, the additional information provided still did not resolve matters. This caused frustration and uncertainty for Ms X. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to, within 6 weeks, provide Ms X with a further complaint response addressing all of the concerns raised in her complaints to the Health Board and to the Ombudsman, and also to provide her with a written apology for not fully addressing all parts of her complaint in its initial response.

Mrs G complained that Swansea Bay University Health Board had failed to respond to the complaint she made to it in July 2024. The Ombudsman found that there had been a delay in the Health Board responding to Mrs G’s complaint and a failure to keep her updated, which caused Mrs G frustration. The Ombudsman decided to settle the complaint without a formal investigation. The Ombudsman sought and gained the Health Board’s agreement to apologise to Mrs G and explain the reason for the delay and failure to provide updates, and to offer her a £250 redress payment within 4 weeks. The Health Board also agreed to issue the complaint response to Mrs G within 10 weeks of the date of this decision.

Mrs X complained that Swansea Bay University Health Board failed to respond to the complaint raised in February 2024. The Ombudsman found that the Health Board had failed to respond to Mrs X’s complaint. The Ombudsman stated that 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 offer Mrs X an apology and explanation for the delay, issue the complaint response and offer a £150 financial redress payment in recognition of the delays, within four weeks

Mr C complained about the care provided to his late mother, Mrs D, by her GP Practice (“the Practice”). Specifically, Mr C complained that there was a failure by the Practice in April and May 2023 to identify that Mrs D was at risk of deep vein thrombosis (“DVT” – a blood clot that develops within a deep vein in the body) and to take appropriate action. The investigation found that the care provided to Mrs D was appropriate and in line with clinical standards. There were no signs, symptoms or mention of DVT which should have prompted action or consideration of Mrs D’s previous history of venous insufficiency (where veins in the leg are damaged and do not work as efficiently as they should). The Ombudsman did not uphold this complaint.

Mrs M complained that Swansea Bay University Health Board had failed to respond to the complaint she submitted in April 2024. The Ombudsman decided that there had been a significant delay by the Health Board to provide Mrs M with a response. She said this had caused frustration and uncertainty for Mrs M. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to apologise to Mrs M and provide her with an explanation for the delays. The Health Board also agreed to provide Mrs M with a redress payment of £150 and to issue a complaint response within 4 weeks.

Mr E complained that while reviewing a CT scan during a consultation on 2 May 2023, a consultant psychiatrist (“the Consultant Psychiatrist”) said that his mother had suffered Transient Ischaemic Attacks (“TIAs” – also known as “mini strokes”, they are caused by a temporary disruption in the blood supply to part of the brain). He said that his mother’s GP had not mentioned any concerns about TIAs when reviewing the CT scan report. He was concerned that, despite expressing these concerns, the Consultant Psychiatrist did not pass this information to other treating clinicians, and that this could have altered his mother’s treatment. Mr E also complained that there was an undue delay in arranging a multi-disciplinary team meeting to review his mother’s care and that there had been a missed opportunity to identify that his mother was at risk of Deep Vein Thrombosis (“DVT” – a blood clot that develops within a deep vein in the body) when she attended for assessment of an ankle injury in May 2023. The Ombudsman decided that there was insufficient evidence of failings in relation to these complaints to warrant an investigation. However, the Ombudsman was concerned that on the balance of the available evidence it was likely that the Consultant Psychiatrist had incorrectly advised Mr E and his mother that the CT scan showed TIAs. Several opportunities were missed at the time and in response to Mr E’s complaints to provide reassurance that this was not the case. The Health Board agreed to a number of actions to resolve the complaint. These included apologising and paying £500 to Mr E to reflect the avoidable distress caused by the uncertainty about potential TIAs. The Health Board also agreed to carry out a review of the way the CT scan was reviewed and communicated to Mr E and his mother.

Mr W complained about the treatment he had received when he attended hospital with suspected sepsis. He said that he had complained to Swansea Bay University Health Board (“the Heath Board”) regarding this but that it had not fully addressed all of his concerns. The Ombudsman found that, whilst the Health Board had issued a complaint response to Mr W, further queries had since been raised which had not yet been addressed. The Ombudsman sought and gained the Health Board’s agreement to, within 1 month, issue a further response to Mr W addressing his concerns.

Miss B complained about the care and treatment provided to her late sister, Miss A, by her GP Practice. The investigation considered whether the decision by Miss A’s GP not to prescribe her with antibiotics, following telephone consultations on 5 and 12 December 2022, was appropriate and whether it was appropriate for the GP to have concluded that a home visit was not necessary. The Ombudsman found that the decision by the GP not to prescribe Miss A with antibiotics following the telephone consultations on 5 and 12 December was not appropriate and furthermore, it was also inappropriate for the GP who spoke to Miss A during the consultations to have concluded that a home visit was not necessary. This was an injustice to Miss A as her presenting symptoms should have resulted in a hospital admission and subsequently, a thorough clinical assessment. Whilst the Ombudsman could not be certain whether Miss A’s outcome would have been any different, this uncertainty is an enduring injustice to Miss B and her family. The Ombudsman upheld the complaint. The Ombudsman recommended that the GP Practice apologise to Miss B, ensure the case is discussed with the GP in question and remind all of its GPs about the importance of recording detailed notes on assessments and examinations carried out on each patient.

Mr B complained about a lack of care and treatment provided to his late mother, Mrs C, by the Welsh Ambulance Services University NHS Trust (“the Trust”) and Swansea Bay University Health Board (“the Health Board”) in September 2022. The Ombudsman’s investigation considered whether the triaging of the emergency calls, and the priority they were allocated by the Trust, was reasonable and appropriate. The investigation also considered whether the advice provided by Trust staff during the calls was reasonable and appropriate. Finally, the investigation considered whether Mrs C was appropriately assessed and managed by the Health Board following her arrival at the Emergency Department of Morriston Hospital on 15 September. The Ombudsman found that the emergency calls were correctly triaged and prioritised by the Trust’s emergency call handlers. However, a clinician on the Clinical Support Desk (“CSD” – a team of clinically trained practitioners who work as part of the Trust’s control room) should have reviewed Mrs C’s case, identified that she was at serious risk and then considered escalating the ambulance response category. If this had happened, an ambulance may have been allocated to Mrs C sooner. This might have reduced the time she spent lying on the floor, which would have been extremely distressing, painful and undignified for her. This complaint against the Trust was upheld. The Ombudsman was concerned that the Trust missed several opportunities to identify this service failure, and that it only acknowledged failings after she shared the views of her Paramedic Adviser in April 2024. The Ombudsman considered that this raised serious concerns about the robustness of the Trust’s investigations of the complaints it receives, particularly as this was not the only case in which she had identified deficiencies in the Trust’s complaints investigation process. In respect of the advice provided by the Trust’s staff, particularly the advice not to move Mrs C, the Ombudsman

Mr B complained about a lack of care and treatment provided to his late mother, Mrs C, by the Welsh Ambulance Services University NHS Trust (“the Trust”) and Swansea Bay University Health Board (“the Health Board”) in September 2022. The Ombudsman’s investigation considered whether the triaging of the emergency calls, and the priority they were allocated by the Trust, was reasonable and appropriate. The investigation also considered whether the advice provided by Trust staff during the calls was reasonable and appropriate. Finally, the investigation considered whether Mrs C was appropriately assessed and managed by the Health Board following her arrival at the Emergency Department of Morriston Hospital on 15 September. The Ombudsman found that the emergency calls were correctly triaged and prioritised by the Trust’s emergency call handlers. However, a clinician on the Clinical Support Desk (“CSD” – a team of clinically trained practitioners who work as part of the Trust’s control room) should have reviewed Mrs C’s case, identified that she was at serious risk and then considered escalating the ambulance response category. If this had happened, an ambulance may have been allocated to Mrs C sooner. This might have reduced the time she spent lying on the floor, which would have been extremely distressing, painful and undignified for her. This complaint against the Trust was upheld. The Ombudsman was concerned that the Trust missed several opportunities to identify this service failure, and that it only acknowledged failings after she shared the views of her Paramedic Adviser in April 2024. The Ombudsman considered that this raised serious concerns about the robustness of the Trust’s investigations of the complaints it receives, particularly as this was not the only case in which she had identified deficiencies in the Trust’s complaints investigation process. In respect of the advice provided by the Trust’s staff, particularly the advice not to move Mrs C, the Ombudsman

Mrs A complained that the GP Surgery failed to investigate what stage her mother’s, Mrs B’s, COPD was at and identify metastatic cancer. The Ombudsman decided that whilst the overall care provided to Mrs B was appropriate, the Surgery managed 4 COPD exacerbations in a row over the telephone, before seeing Mrs B for an in person consultation, when it would have been appropriate to have seen her in person sooner. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Surgery’s agreement, that within 4 weeks it would send a written apology to Mrs A for not seeing her mother in person at an earlier stage after her COPD exacerbations.

Mr A complained that Swansea Bay University Health Board had not fully responded to his concerns about the care and treatment provided to him by the persistent pain team and a referral to physiotherapy. The Ombudsman’s assessment found that the Health Board had blocked email contact from Mr A and had informed him of this in a letter. However, this letter did not adequately explain to Mr A the options available to him for submitting a complaint to the Health Board. As it had not received his complaint, the Health Board had not yet investigated nor responded to his concerns. The Health Board agreed to, within 2 weeks, provide Mr A with details of the options available to him for submitting a complaint to the Health Board. It also agreed to conduct an investigation into the complaint raised by Mr A regarding the care and treatment provided by the persistent pain team and referral to physiotherapy. The Health Board agreed to provide Mr A with a full response to his complaint within 4 weeks.

Mrs C complained about the care and treatment her late mother, Mrs A, received from Swansea Bay University Health Board when she was admitted to Singleton Hospital between 11 May and 17 June 2022. The investigated considered whether: a) Mrs A’s nutritional needs were met b) the dosage of lorazepam prescribed during Mrs A’s admission was clinically appropriate c) the continence care provided was of a reasonable standard, including whether laxatives were prescribed prior to Mrs A’s discharge The Ombudsman’s investigation found that there were some failings in relation to Mrs A’s nutritional needs and continence care and upheld these aspect of Mrs C’s complaints. The investigation found no evidence that Mrs A was prescribed laxatives on discharge from the Hospital. The Ombudsman was satisfied with the Health Board’s explanation that the increase in Mrs A’s lorazepam dosage was appropriate because it was due to her confusion and agitation. We therefore did not uphold this aspect of her complaint. The Ombudsman was pleased to note the Health Board has already put measures in place to address the areas of poor care and documentation that have been identified. Had it not done so, these would have formed part of the recommendations. The Ombudsman recommended that the Health Board apologise again to Mrs C for the failings identified by the investigation and provide evidence of the actions taken to address the documentary and clinical shortcomings to this office.

Ms C complained about the care and treatment her late father, Mr D, received from Swansea Bay University Health Board. She complained about whether it was appropriate to discharge Mr D from hospital on 24 December 2023. She also complained about whether there was delay in treating Mr D in the 2 days following his readmittance to hospital on 27 December 2023. The investigation found that, while it was not reasonable to discharge Mr D on 24 December, this did not alter his outcome. The investigation also found that there was no delay in treating Mr D when he was readmitted to hospital. These complaints were not upheld.

Miss B complained about the care and treatment provided to her late son, Mr C, by a GP Practice in the area of Swansea Bay University Health Board. Specifically, the investigation considered whether appropriate clinical care and treatment was provided in relation to Mr C’s mental health between November 2021 and December 2022. The Ombudsman found that the Practice acted reasonably in relation to the mental health care and medication provided to Mr C. However, the clinical care provided by the Practice to Mr C fell below an appropriate standard, on the basis that it did not undertake an adequate or appropriate medication review on 3 August 2022. Although it was unlikely there was any reasonably foreseeable risk of Mr C’s overdose at the time his medication was reviewed, the level of uncertainty is an injustice to Mr C’s family. To that extent, the Ombudsman upheld this complaint. The Ombudsman recommended that the Practice provide Miss B with a written apology for the failures identified by the Ombudsman’s investigation, offer redress of £500 in recognition of failings identified, and share a copy of the investigation report with the Practice GPs. It was also recommended that the Practice review its medication review process to include reasonable attempts at patient contact where clinically indicated or indicated by relevant guidance.

Ms X complained that a Medical Centre in the area of Swansea Bay University Health Board failed to respond to her complaint submitted to it in October 2024 regarding her abdomen scans. Ms X also complained that it failed to follow its complaints process and had published incorrect contact details for making a complaint. The Ombudsman concluded that the Medical Centre had failed to formally respond to Ms X’s complaint, although noted that the Practice considered that the matter had been resolved during a GP consultation. The Ombudsman said the lack of response caused uncertainty, frustration, and inconvenience to Ms X. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Medical Centre’s agreement to issue Ms X with a complaint response within 2 weeks. The response should also include an apology and an explanation for the delay.