PSOW Individual Decisions

Ms K said that Swansea Bay University Health Board failed to provide a response to her complaint, about the treatment provided to her late mother, which she made to it in December 2023. The Ombudsman found that the Health Board had not provided regular and meaningful updates to Ms K and had not issued a complaint response. She said that this caused frustration and uncertainty to Ms K. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to write to Ms K with an apology for the identified failures and to offer Ms K £150 redress in recognition of her time and trouble in making a complaint to the Ombudsman within 2 weeks. It was further agreed that a complaint response would be issued within 6 weeks.

Mr T complained that Swansea Bay University Health Board had not responded to his complaint and had not arranged adequate care and assistance when discharging his wife from hospital. The Ombudsman found that the Health Board had failed to provide Mr T with a complaint response 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 provide an apology and explanation for the delay and issue its complaint response within 4 weeks and offer Mr T £150 financial redress for the time and trouble taken to approach the Ombudsman.

Miss L said that Swansea Bay University Health Board failed to provide a response to her complaint which she made to it in February 2024. The Ombudsman found that the Health Board had failed to issue a complaint response and had not provided regular and meaningful updates. She said that this caused frustration and uncertainty to Miss L. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to write to Miss L with an apology for the identified failures, and to issue a complaint response within 6 weeks.

Mrs B complained that she submitted a complaint to the Health Board in July 2023. This was regarding the care and treatment her late father received at Neath Port Talbot Hospital, and his premature discharge to a care home, which she said contributed to his death. Mrs B had still not received a response to her complaint a year later. Mrs B wanted this to be completed, and amongst other things, to have an opportunity to speak to staff to discuss the complaint outcome. The Health Board agreed to issue the complaint response within 20 workings days and, as part of that response, to offer Mrs B a meeting to discuss the complaint outcome. The Ombudsman considered this to represent an appropriate outcome and closed the case on this basis.

Ms X complained that Swansea Bay University Health Board had failed to respond to her complaints, the first submitted in July 2023 and the second submitted in January 2024. The Ombudsman concluded that the Health Board had responded to the first complaint but found that a response had not been issued in respect of the second complaint and whilst the Health Board had provided updates, they had not been regular. The Ombudsman said this caused frustration to Ms X. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to apologise to Ms X for the delay and lack of updates, to pay Ms X £50 redress for the identified failures and to issue a complaint response within 3 weeks.

Ms J complained on behalf of her Client, Ms X, that Swansea Bay University Health Board had not responded to a complaint raised in February 2024. The Ombudsman found that whilst the Health Board is within the 6-month time frame set out in NHS Regulations, it has not kept Ms J or Ms X updated. 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 issue its complaint response within 2 weeks. It also agreed that if this time scale can not be achieved, it will send monthly, meaningful update letters.

Mr X complained that Swansea Bay University Health Board had failed to respond to his complaint, made to it in June 2023, and had not kept him properly updated. The Ombudsman found that there was an unacceptable delay in the Health Board responding to the complainant and a lack of regular or meaningful updates being provided to Mr X, which she said caused him frustration. She decided to settle the complaint without a formal investigation. The Ombudsman sought and gained the Health Board’s agreement to apologise to Mr X for the delay and lack of updates, to explain the reasons for this, to offer him a £250 redress payment and to issue its complaint response within 6 weeks.

Mrs B complained that Swansea Bay University Health Board failed to respond to the complaint she made to it in January 2024 and she had to chase it for updates. The Ombudsman found that, although the Health Board had spoken to Mrs B by telephone in January, there was a delay in the Health Board providing a written response to the complaint. The Health Board had also failed to properly update Mrs B. The Ombudsman said this caused frustration to Mrs B and decided to settle the complaint without a formal investigation. The Ombudsman sought and gained the Health Board’s agreement to apologise to Mrs B, explain the reason/s for the delay, offer a £100 redress payment, and to issue its complaint response within 4 weeks.

Dr C complained about the care and treatment that he received from the Health Board after he was diagnosed with myeloma (a type of blood cancer). The investigation considered whether: a) A stem cell transplant was appropriately considered, in view of national guidelines and the COVID-19 pandemic during a telephone consultation on 20 October 2020. b) A light chain assay test (a blood test used in the diagnosis and monitoring of myeloma) should have been requested following a consultation on 3 February 2021, instead of later in June, the results of which suggested biochemical disease progression. c) Dr C’s ongoing treatment and disease progression were appropriately managed. The Ombudsman concluded that whilst the initial decision to defer Dr C’s stem cell transplant was reasonable due to the onset of the pandemic, treatment options and decisions should have been reviewed on a regular basis and discussed with Dr C, including during a consultation in October 2020. In addition, the Ombudsman found that Dr C should have been offered maintenance therapy after the decision to defer the transplant. The Ombudsman also noted that a request for a light chain assay had been missed from blood request forms in preparation for Dr C’s consultation in May 2021 and that there were other gaps in monitoring in early 2021. As a result, the Ombudsman upheld Dr C’s complaints. The Health Board agreed to: • Provide Dr C with a meaningful apology for the failings identified. • Share the report with the Consultant Haematologist for reflection, learning purposes and discussion at his next appraisal. • Discuss the report at a Quality and Safety meeting, or in an alternative appropriate forum, and provide feedback on whether there are any wider actions or improvements that should be taken forward as a result of that discussion. • Ensure that there is a formalised review process in place for the regular monitoring of myeloma patients, including assurances that all the required blood tests have b

Mr D was admitted to Morriston Hospital with declining health in November 2021. Concerns included a slow heart rate, raised inflammatory markers, and his kidneys were not working properly. Mr D had a prosthetic heart valve fitted in 2011 and it was suspected by the Cardiology Team that blood was leaking from around his prosthetic valve. Mr D stayed in hospital undergoing treatment which included a course of antibiotics which was given for 6 weeks. Doctors had decided by the week leading up to Christmas that Mr D was fit for discharge and therefore he was discharged home on 24 December. Sadly Mr D died later that day.. The Ombudsman investigated whether the management of Mr D’s discharge had been reasonable; in particular, whether the decision to withdraw antibiotic treatment and not to request a review from the Palliative Care Team at discharge had been appropriate. The Ombudsman found that it was appropriate to consider palliative care when Mr D was first admitted because he was seriously unwell. However, he completed a clinically appropriate course of treatment in the Hospital, for a time period that was in line with relevant guidelines. Although his antibiotic treatment could have been extended, Mr D had responded positively to that treatment and was stable before he was discharged. There was no indication that a palliative care review should have been undertaken, given Mr D’s improvement. The complaint was not upheld

Mr H complained that Swansea Bay University Health Board had failed to respond to the complaint he made to it in November 2023. The Ombudsman found that the Health Board had provided some updates to Mr H, but there had been a delay in responding to his complaint. The Ombudsman said this caused frustration to Mr H and decided to settle the complaint without a formal investigation. The Ombudsman sought and gained the Health Board’s agreement to apologise to Mr H for the delay in responding to him and to issue its complaint response to him within 2 weeks.

Mr A complained that he had waited for 6 years for knee replacement surgery from the Health Board and that it had not replied to his complaint. The investigation found that it was unclear whether the Health Board had received Mr A’s complaint and that it had not been investigated internally. It was therefore not possible to say whether the Health Board agreed with or rejected Mr A’s concerns. In order to progress Mr A’s complaint, the Health Board agreed to investigate his concerns by following the formal complaints process. Mr A would be able to return to the Ombudsman with his complaint in due course if he was not satisfied with the Health Board’s final response.

Ms B complained that she was inappropriately discharged from mental health services in Swansea Bay University Health Board in August 2022. The investigation found that Ms B’s discharge from mental health services in August 2022 was appropriate and in line with routine clinical management. However, the investigation also found that Ms B was not offered a copy of her discharge letter and to this limited extent her complaint was upheld. The Health Board agreed to apologise to Ms B. It also agreed to review its approach to offering copies of outpatient clinic letters within this service and how it could comply with relevant guidance relating to this.

Mr Y complained that the Practice had not responded to his complaint about the care and treatment provided to his late mother. The Ombudsman found that it had been 6 months since the Practice acknowledged the complaint, but it had not investigated or provided a response. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Practice’s agreement to apologise to Mr Y and provide a complaint response, within 10 working days.

Mr B complained because he was unhappy with the actions of a GP Practice in the area of Swansea Bay University Health Board (“the Practice”) following the way he was spoken to during a telephone call with a doctor. He was unhappy that his written complaint was responded to by the same doctor. The Ombudsman decided that it was not appropriate for Mr B’s complaint to be responded to by the person named as the subject of the complaint. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Practice’s agreement to write to Mr B within 10 working days to apologise for how his complaint was dealt with, and to explain the changes the Practice has made to prevent a repeat occurrence.

Ms X complained that Swansea Bay University Health Board had failed to respond to her complaint, or provide regular updates, in respect of her complaint submitted to it 8 months ago. The Ombudsman decided that the Health Board had failed to provide Ms X with a response, and regular updates, which caused frustration and uncertainty to Ms X and led her to contact the Ombudsman. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to issue its complaint response (within 2 weeks), which should also include an explanation and apology for the delay, plus a redress payment of £250.

Miss A complained to Swansea Bay University Health Board (“the Health Board”) about its handling of an alleged assault and recent threats of assault from a fellow member of a support group for autistic adults run by the Health Board. The Ombudsman found that the handling of the alleged assault which occurred in 2018 was out of time for her consideration. However, the Ombudsman did not agree with the Health Board’s assertion that it could not control threats made ‘outside of the Health Board’ as it was clear that the threats related directly to the group’s activities and referenced the group directly. The Ombudsman sought and gained the Health Board’s agreement to, within 20 working days, reconsider the issue relating to the threatening messages sent to Miss A and the implications this may have on the group, and provide a full written response to her addressing her concerns about the threatening messages.

Mr R complained that Swansea Bay University Health Board had reset the referral to treatment time (“RTT”) clock for him to undergo a left hip arthroscopy after he was unable to attend an appointment. He said that this was the only appointment that he had been unable to attend, and that the reason for this was the short notice he was given. Mr R said that the decision to reset his RTT clock was unfair and not in line with Welsh Government guidelines. The Health Board agreed that there had been an error in resetting Mr R’s RTT clock. It agreed to correct the misapplied reset and to write to Mr R to apologise and explain the error and to clarify his true RTT clock time and estimated date for treatment. The complaint was settled on that basis.

The Ombudsman investigated a complaint from Mr Y about the way that a trainee GP at the Practice had managed the care of his late wife, Mrs Y, when she had contacted the Practice complaining of a history of 10 days constipation and abdominal pain. A telephone appointment was arranged with the trainee GP who was of the opinion that Mrs Y was suffering from constipation as a result of low fluid intake. He did not arrange to see Mrs Y but told her that if she displayed any “red flag” symptoms she should attend the Emergency Department. 4 days later Mrs Y was admitted to hospital and underwent investigations which identified that she had a bowel perforation in 2 places. Sadly, despite undergoing surgery, Mrs Y died2 days later multi-organ failure, sepsis and perforated colon. The Ombudsman found that there was a failure to take clinically appropriate action and to arrange a face-to-face consultation with Mrs Y, based on the symptoms she presented with during the telephone consultation on 19 July 2021. It was considered, that on balance, a more thorough assessment or clinical examination may have changed the diagnosis of constipation or may have led to a consideration that Mrs Y was suffering from a more serious underlying cause for the constipation, that needed further investigation. The Ombudsman upheld the complaint and recommended that the Practice apologise to Mr Y as it was responsible for the service being delivered to their patients. The Ombudsman did not identify an issue with the manner the trainee GP was being supervised. The Ombudsman would have made a number of recommendations to ensure that the trainee GP reflected and learned from this event to ensure the same shortcomings did not happen again. However, since Health Education and Improvement Wales had already ensured that all relevant actions had been undertaken as part of its usual processes, the Ombudsman was satisfied that no further recommendations were required to ensure future learning and improvemen

Miss T complained that Swansea Bay University Health Board failed to provide a response to the complaint she made about the care and treatment provided to her late father which she made to it in August 2023. The Ombudsman found that whilst the Health Board had provided updates, they had not been regular, and a complaint response had not been issued. She said that this caused frustration to Miss T. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to write to Miss T with an apology for the identified failures, to pay £75 redress to Miss T for her time and trouble in raising a complaint with the Ombudsman and to issue a complaint response within 4 weeks.

Mrs A complained about the care and management she had received since November 2018 under the Colorectal Team at Morriston Hospital (“the Hospital”). This included the failure to fit a colostomy bag during surgery in early November 2018, which meant that she developed life threatening/changing complications and later required emergency surgery to fit the colostomy bag. She was concerned about the lack of a treatment plan to address the problem, and repeated appointments. She was also unhappy with Health Board’s handling of her complaint. We found that Mrs A’s inpatient medical and nursing care on 1 November and her subsequent inpatient admissions were broadly reasonable and appropriate, and this aspect of her complaint was not upheld. The Ombudsman’s investigation found significant shortcomings, including protracted delays in Mrs A’s management and care with no clear treatment plan being put in place to address her ongoing complications. There was also a lack of coordinated clinical decision-making and rationale by the clinicians involved in Mrs A’s care which was not in keeping with accepted clinical practice. These clinical shortcomings were compounded by the lack of access to operating theatres and cancellation of outpatient appointments. The Ombudsman concluded that a timelier intervention might have alleviated some of Mrs A’s symptoms and reduced the impact on her mental health and wellbeing sooner than occurred. It may also have lessened the wider effects on her family and the relationship she had with them. Whilst the Ombudsman is not able to make definitive findings of a breach of the Human Rights Act, she can comment on the Health Board’s regard for these rights. The Ombudsman was satisfied that both Mrs A and her family’s Article 8 rights were engaged as the failure to address Mrs A’s ongoing issues with her fistula meant that her dignity was compromised. Given the embarrassment caused to Mrs A by the daily leakage from her back passage, she did not feel c

Mr F complained that Swansea Bay University Health Board failed to respond to the complaint he made to it in July 2023. The Ombudsman found there had been a delay in the Health Board responding to Mr F’s complaint. She said that this caused frustration for Mr F. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to apologise to Mr F, offer him a redress payment of £100, and issue its complaint response within 6 weeks.

Mrs Z complained about the treatment her late husband, Mr Z, received from Swansea Bay University Health Board (“the Health Board”). Mrs Z complained that Mr Z should have been re-admitted to Morriston Hospital before 22 November 2020 and that an earlier admission to hospital, and treatment, would have significantly altered his outcome. The investigation found no evidence that an earlier admission to hospital would have altered the outcome for Mr Z. The Health Board’s failure to action a referral for an inpatient admission on 16 November 2020 was found not to have adversely impacted Mr Z. His leg wound was responding to the oral antibiotics he was prescribed at that time and his subsequent deterioration and re-admittance to hospital on 22 November was not due to this. On this basis, the complaint was not upheld.

The investigation found that Mrs A was not fully aware of how unwell her husband was, and the paramedics and clinicians ought to have known this and further consideration should have been given to involving Mrs A in her husband’s care. Mrs A was not informed about the do not attempt cardiopulmonary resuscitation (“DNACPR” this informs clinicians that a patient does not wish to be resuscitated if their breathing or heart stops), which was discussed with Mr B in the early hours of the morning. Mrs A should have been informed of the DNACPR decision as soon as it was practically possible. These issues, combined with the overall failure to communicate with Mrs A about how unwell Mr B was, meant that the Health Board missed the opportunity to update Mrs A about her husband’s condition and treatment. The Ombudsman recognised that this was challenging for the Health Board in the context of the COVID-19 restrictions, however it also meant that Mrs A’s opportunity to be with her husband was further limited. Given this more thought and urgency should have been given to communicating an updated position with her sooner than in fact occurred. The Health Board had previously offered its unreserved apology for this missed opportunity, and for the impact this had had on Mrs A. The Ombudsman upheld Mrs A’s complaint, to the extent that the overall communication shortcomings meant that she was not able to be involved in her husband’s care or be present at the end of his life to reassure and support him, and this was an enduring injustice to Mrs A. The Ombudsman recommended that WAST and the Health Board apologise to Mrs A for the failings identified in the investigation. WAST, as part of wider learning, was asked to carry out a clinical review of Mr B’s case and discuss clinical features and management with the attending crew including the appropriateness of time at the scene and documenting. The Health Board was asked, if it had not already done so, to remind the medical and nursing

Mrs A complained about Welsh Ambulance Services NHS Trust (“WAST”) and Swansea Bay University Health Board (“the Health Board”). The investigation considered Mrs A’s complaint about the care her late husband, Mr B, received from WAST. Mrs A complained about the delay in an ambulance arriving following her 999 calls and questioned whether the 999 calls were correctly categorised. She also complained that a further delay in transporting Mr B to the Emergency Department (“ED”) at Morriston hospital (“the Hospital”) affected his prognosis. In relation to the Health Board, the investigation considered whether the care provided to Mr B was timely and appropriate and a failure to communicate her husband’s deteriorating condition meant that she was unable to be with him during his final hours. The investigation found that the 999 calls to WAST were correctly categorised and appropriately prioritised and that the delay in an ambulance reaching Mr B was outside of WAST’s control due to the pressure on its services. The Ombudsman did not uphold this part of Mrs A’s complaint. The investigation found a missed opportunity to recognise Mr B’s heart failure and change the treatment regime and consider further treatment intervention. That said the Ombudsman was satisfied that it was extremely unlikely that, had Mr B been taken to hospital earlier and heart failure treatment had started sooner, the outcome would have changed. The investigation concluded that the lack of a documented reason for the paramedic delay and the lack of timeliness in transporting Mr B to the Hospital was not reasonable or appropriate and, to that extent, represented a service failure which caused distress and upset to Mrs A, and her complaint was upheld to a limited extent. In relation to Mrs A’s complaint about the Health Board and the care Mr B had received in Hospital, the investigation concluded that the care provided to Mr B was timely and appropriate and therefore the Ombudsman did not uphold the comp