PSOW Individual Decisions

Mr R complained about the care and treatment provided to his wife, Ms R, by a GP Practice in the area of Swansea Bay University Health Board. Specifically, the investigation considered whether a decision to prescribe naproxen (part of a group of medication knows as NSAIDs used to treat plan, inflammation and fever) without a proton pump inhibitor (“a PPI” – medication that reduces acid production in the stomach) was clinically appropriate and whether the prescribing of naproxen, without a PPI, likely caused Ms R to suffer a gastrointestinal bleed and/or stroke (where the blood supply to part of the brain is cut off, causing damage to the brain). The investigation found that Ms R was prescribed a high dose of naproxen and as such the prescription of a PPI should have been offered alongside it. The failure to prescribe a PPI placed Ms R at an avoidable increased risk of experiencing an adverse gastrointestinal event. This part of Mr R’s complaint was upheld. The investigation also found that it was more likely than not that the prescription of naproxen caused Ms R to suffer a gastrointestinal bleed. A prescription of a PPI alongside naproxen would have reduced the risk of this occurring. It can never be known for certain what the outcome for Ms R would have been had a PPI been prescribed with naproxen. This will be a source of lasting uncertainty, which is an injustice. This part of Mr R’s complaint was upheld. The Ombudsman sought and gained the GP Practice’s agreement to apologise to Mr R and Ms R for the failure to offer Ms R a PPI, and to offer them a payment of £500 in recognition of the uncertainty and distress caused by this failure. It also agreed to ensure the GP who prescribed naproxen to Ms R is familiar with NICE guidance on prescribing NSAIDS, in particular how to mitigate any risks this may present through the use of a PPI and the importance of discussing risks with patients.

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

Mrs X complained that Swansea Bay University Health Board had failed to respond to her mother’s, Mrs Y’s, complaint. The Ombudsman found that, while the Health Board provided Mrs Y with some updates within the expected timeframe, on other occasions Mrs Y had to chase the Health Board for an update regarding her complaint, and it had failed to provide her with a response. The Ombudsman said that this caused uncertainty and frustration for Mrs Y. She 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 Y with an apology and explanation for the delay and lack of regular updates, issue its complaint response, and offer to pay Mrs Y £50 in recognition of the delay and lack of regular updates.

Mr F complained about the care provided to his late mother Mrs G. The investigation considered whether the action taken by the Acute Clinical Team in respect of his late mother’s blood test results between 25 May and 2 June 2023 was clinically appropriate. The investigation found that Mrs G’s blood test results showed that her condition was deteriorating between 25 May and 2 June 2023. As such, she should have been admitted to hospital, and not discharged to the care of her GP. Records kept regarding Mrs G’s condition during this time were not always clear. These were failings by the Health Board. Mr F will be left with lasting uncertainty about what the outcome may have been had these failings not occurred, which is an injustice to him. Mr F’s complaint was upheld. The Health Board agreed to apologise to Mr F for the failings identified during the investigation. It also agreed to remind the clinicians involved in Mrs G’s care of the importance of keeping accurate records and to ensure they are familiar with the management of deteriorating blood test results.

Dr C complained about the care and treatment provided to his wife, Dr E. Specifically, Dr C was concerned about whether appropriate cardiological tests were carried out when Dr E attended hospital in July 2023. The investigation found that appropriate levels of care were delivered to Dr E. When Dr E attended hospital she was thoroughly assessed and the view of a cardiologist was sought regarding her treatment. The Ombudsman did not uphold this complaint.

Mrs A’s complaint centred on whether she should have been listed for knee replacement surgery following her consultation on 2 January 2020, and whether the decision to discharge her from the orthopaedic clinic in December 2020 was appropriate. The Ombudsman was satisfied that given Mrs A’s high Body Mass Index (“BMI”), not listing her for surgery was reasonable, as the effects of a high BMI were explained to Mrs A. The Ombudsman was pleased to note that the Health Board now books a patient in for surgery along with providing support for the patient to lose weight. She was also satisfied that the decision to discharge Mrs A from the orthopaedic clinic was appropriate given the COVID-19 pandemic and that Mrs A was advised of this in writing and her GP was also copied in. The letter also advised Mrs A that she could contact her GP to be re-referred if her condition worsened. The Ombudsman did not uphold Mrs A’s complaint.

Ms B complained that Swansea Bay University Health Board had failed to respond to the complaint she made to it in April 2024. The Ombudsman found that the Health Board had not responded to the complaint, causing frustration to Ms B. The Ombudsman decided to settle the complaint without a formal investigation. The Ombudsman sought and gained the Health Board’s agreement to apologise to Ms B for the delay, explain the reasons for the delay, and to issue its complaint response within 4 weeks.

Mrs C complained on behalf of her husband, Mr C, about the care and treatment he received from Swansea Bay University Health Board relating to delayed mouth cancer diagnosis and treatment, following an Urgent Suspected Cancer (“USC”) referral on 24 February 2023. The investigation considered whether there were inadequate investigations and diagnostic assessments following the first consultation on 7 March, leading to an incorrect diagnosis and inappropriate debridement treatment on 28 March. The investigation also considered whether there were delays with subsequent diagnostic assessments and obtaining results, which further delayed Mr C’s diagnosis of mouth cancer and caused delays in treatment via surgery. The Ombudsman found that the clinical investigations and diagnostic assessments following Mr C’s first consultation on 7 March were appropriate and reasonable. The debridement treatment was found to be appropriate, and diagnostic assessments were requested and carried out within appropriate timeframes. These aspects of the complaint were not upheld. However, there was a delay in reporting the biopsy histology and a delay in the timeframe for surgery. Although the delays did not result in any impact on the overall prognosis or outcome for Mr C, the distress caused by the prolonged wait, and the fact that the surgical treatment was more extensive than it may otherwise have been, was an injustice to Mr C. The Ombudsman upheld this part of the complaint. The Ombudsman recommended that the Health Board apologise for the failings identified; review its guidance/procedure regarding timescales for reporting and returning biopsy pathology; share the report with clinicians in the Head and Neck specialism; and provide the Ombudsman with evidence of the improvements in current treatment times indicated by the Health Board.

Miss C complained on behalf of her son, B, about the treatment he received for obsessive compulsive disorder (“OCD” – a mental health condition where a person has obsessive thoughts and compulsive behaviours). The investigation considered whether the decision not to prescribe B with medication to treat his OCD in September 2022, was clinically appropriate. The investigation found that the decision not to prescribe B medication was in line with the relevant guidance and was therefore clinically appropriate. The Ombudsman did not uphold this complaint.

Mrs A complained that Swansea Bay University Health Board had failed to formally respond to her letters of complaint, in relation to her late grandmother’s care. The Ombudsman found that the Health Board had discussed Mrs A’s concerns with her in a meeting but it had failed to formally respond to the letters, despite a request by Mrs A to do so. The Ombudsman said this had caused frustration and inconvenience to Mrs A. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to apologise to Mrs A and issue a complaint response within 4 weeks.

Mr A had complained to the Health Board about the care and treatment provided to his late father. The Health Board responded to his complaint in July 2024, where it offered a meeting if it had not addressed his complaint to his satisfaction. Mr A complained to this office that despite requesting a meeting with Health Board staff to discuss his ongoing concerns, a meeting was not arranged in a timely manner. The Ombudsman was concerned that the Health Board had failed to arrange a meeting with Mr A, despite its complaint response letter stating that such a meeting could be arranged. Instead of investigating this complaint, the Ombudsman obtained the Health Board’s agreement to arrange a meeting with Mr A and to apologise for failing to do so in a timely manner in the first instance. The Health Board agreed to undertake these steps within 2 months.

Mrs A complained about the care and treatment her late mother, Mrs B, received from Swansea Bay University Health Board. Specifically, the investigation considered whether the management of Mrs B’s condition, when she was admitted to Morriston Hospital on 2 January 2023, was clinically appropriate. The investigation found that the management of Mrs B’s condition when she was admitted to hospital on 2 January 2023 was clinically appropriate. The Ombudsman did not uphold this complaint.

Mrs C complained about the care provided to her 2-week-old son, A, by Swansea Bay University Health Board on 21 January 2023. Very sadly, A died on 24 January. The investigation considered whether clinicians at the children’s Emergency Department (“the ED”) at Morriston Hospital: a) Appropriately investigated and assessed A’s symptoms prior to discharging him. b) Gave appropriate advice about what signs to look out for that might suggest a need to seek further medical attention for A. The investigation found that the assessment and investigation of A’s symptoms by clinicians at the ED was appropriate. It also found that appropriate advice was provided at the time he was discharged from the ED. The Ombudsman did not uphold the complaints.

Mr B complained about the care and treatment provided to his late mother, Mrs A, by Swansea Bay University Health Board. Specifically, the investigation considered: a) Whether Mrs A’s treatment for a pulmonary embolism (“PE” – a serious condition caused by a blood clot in the lungs) between 9 December 2020 and 27 January 2021 was appropriate b) Whether it was reasonable for Mrs A to have been discharged from hospital on 15 December 2020 c) Whether it was appropriate for Mrs A to have been treated on a COVID-19 ward following her admission on 4 January 2021, and whether all reasonable infection control measures were taken. The investigation found that the care and treatment provided to Mrs A by the Health Board between 9 December 2020 and 27 January 2021 was appropriate. This included the treatment for a PE, the discharge decision on 15 December 2020 and the treatment Mrs A received after she was admitted to a ward on 4 January 2021. Complaint c) was upheld to the limited extent that there had been a failure to record the reasons for the decision to admit Mrs A to the ward despite it having been closed due to an outbreak of COVID. This meant that the Ombudsman could not determine whether the decision was appropriate, which was an injustice to Mr B. The Health Board agreed to the Ombudsman’s recommendations to apologise to Mr B for the failings identified and to take steps to ensure that in the future, the specific reasoning for any decisions to admit patients to wards which have been closed due to an outbreak, are clearly documented in the patient’s notes.

Mr M complained that the Practice had failed to respond to his complaints about the poor care and treatment provided to him. The Ombudsman found that the Practice had responded to one complaint but that there had been a failure to respond to the second complaint and this had caused frustration and uncertainty for Mr M. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the agreement of the Practice to apologise to Mr M and provide him with a complaint response within 3 weeks.

Mrs A complained about the care and treatment provided to her late father by the Practice. Mrs A further complained about communication difficulties and the conduct and attitude of staff. Mrs A was dissatisfied with the complaint response provided by the Practice. The Ombudsman was concerned about the Practice’s complaint handling. The Practice had not responded to the first complaint made by Mrs A and its response to her second complaint did not adequately address the matters raised. This caused inconvenience, stress and upset for Mrs A and her family. The Ombudsman decided to settle the complaint without an investigation. The Practice agreed to, within 4 weeks, provide Mrs A with a written apology for the failure to investigate and provide a formal response to her first complaint, the delay in providing a formal response to her second complaint and the failure to fully address matters within its complaint response. The Practice also agreed to provide Mrs A with a further complaint response addressing all matters contained in her complaints.

Mrs A complained about the care and treatment that her husband received. Specifically, she said that the Health Board had failed to respond to all of her concerns about his treatment and discharge. The Ombudsman decided that the Health Board had provided a response to Mrs A’s complaint. In making her complaint to the Ombudsman, it was note that Mrs A had raised questions which she had not previously raised in her initial complaint to the Health Board. The Ombudsman concluded that the Health Board had not had an opportunity to respond to all of Mrs A’s concerns. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement that, within 6 weeks, it would write a letter to Mrs A in response to the outstanding questions.

Mr Y said that the GP Practice, in the area of Swansea Bay University Health Board (“the Practice”) had lost a letter from his late mother’s Optician referring her for further investigations. The Practice confirmed that it had received the letter, but did not explain why there was a 3-month delay in any action being taken. This was a service failure on the part of the Practice in dealing with correspondence. As the issue was not fully addressed in the complaint response received by Mr Y, it was not clear what the circumstances were that caused this failure. It cannot be known what the impact of this was on Mr Y’s mother, which is an injustice to him as he will be left with lasting uncertainty about this. The Practice agreed that, within 1 month, it would apologise to Mr Y for not acting more promptly on the Optician’s referral and the uncertainty this caused. It also agreed, within 2 months, to investigate the circumstances that led to the referral not being acted on and make any necessary changes to prevent this happening again. It agreed any proposed actions will be shared with the Ombudsman.

Miss H complained that Swansea Bay University Health Board failed to provide a formal written response to a complaint she raised about the care and treatment she received following a road traffic collision. She also complained that she had not received the results of an MRI scan. The Ombudsman found that the Health Board closed the complaint without issuing a formal written response and its system failed to automatically send the MRI results to Miss H’s GP. She said this caused additional frustration and uncertainty for Miss H and decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to reopen the complaint to issue a written response. To write to Miss H to apologise for the delay issuing the MRI results and to explain what went wrong. It also agreed to offer financial redress of £50.

Mr C who had complained to the Dental Practice about the poor fitting dentures that he had paid for, was unhappy that in a telephone conversation the Dental Practice had informed him that he had been “struck off their register” due to a breakdown of trust. Mr C, who had been refunded the cost of his treatment, said that he was now having to find a new NHS Dentist. He wanted an apology for the way he had been treated. The Ombudsman found no evidence that the decision itself to remove Mr C from the Dental Practice’s register was improperly taken. However, the Dental Practice accepted that there was a shortcoming in its complaint handling process and how it how it had applied its removal policy (“the Policy”) in Mr C’s case. In particular, it had not written to him setting out the reasons for its decision to remove him from its dental list. In reviewing the Policy, the Ombudsman concluded that there was a degree of ambiguity about the circumstances when a letter would be written to a patient. The Dental Practice agreed as part of a settlement that it would apologise to Mr C for the shortcomings identified in the way that it followed the Policy. In addition, it would amend the Policy so that it was clear that a letter would be sent in all cases about a patient’s removal and relevant information provided in relation to NHS patients.

Ms H complained that Swansea Bay University Health Board failed to provide a response to her complaint initially made by her late mother, which was made to the Health Board on 12 January 2024. The Ombudsman found that the Health Board had failed to issue a complaint response. She said that this caused uncertainty and frustration to Ms H. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to write to Ms H with an apology and explanation for the delay in issuing its complaint response, offer to pay Ms H £75 for her time and trouble in making a complaint to the Ombudsman and issue a complaint response within 4 calendar weeks.

Ms X complained that Swansea Bay University Health Board had failed to respond to her complaint regarding the care and treatment of her late mother, submitted to it in September 2022. The Ombudsman decided that there had been a substantial delay in the complaint response, which caused uncertainty, frustration, and inconvenience to Ms X. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to issue its complaint response, an apology for the delay and inconvenience caused, and a redress payment of £100 (within 3 weeks) in recognition of the delays and need to approach the Ombudsman.

Mr C complained about care provided to his mother, Mrs D, by Swansea Bay University Health Board in May 2023. Specifically, he was concerned that a consultant psychiatrist had noticed that his mother had suffered a Transient Ischaemic Attack (“TIA” – also known as “mini strokes”, they are caused by a temporary disruption in the blood supply to part of the brain). He said that, despite this, the Consultant Psychiatrist did not pass the information to other treating clinicians, and that this could have altered Mrs D’s treatment. He was also concerned that there had been a failure by the Health Board’s Emergency Department to identify that his mother was at risk of Deep Vein Thrombosis when she attended for assessment of an ankle injury. The Ombudsman was concerned that the Health Board had not fully addressed the concerns set out above in its response to Mr C. In the interests of settling the complaint, the Health Board agreed to provide Mr C with a further complaint response within 8 weeks, addressing the outstanding issues, as specified by the Ombudsman.

Mr X complained that Swansea Bay University Health Board had failed to respond to his complaint regarding the treatment his father received. The Ombudsman concluded that the Health Board had provided regular updates to Mr X, but it had failed to issue a complaint response. She said this caused frustration and uncertainty to Mr X. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to within 4 weeks, issue its complaint response, write to Mr X with an apology and explanation for the delay and offer to pay £50 redress in recognition of the time and trouble in his need to approach the Ombudsman.