PSOW Individual Decisions

Mrs A complained that a GP Practice in the area of Swansea Bay University Health Board had failed to respond to her complaint, made to the Practice in September 2022, about the care provided to her late mother. The Ombudsman found that there had been an unacceptable delay in the Practice responding to Mrs A’s complaint and it had failed to provide Mrs A with regular and/or meaningful updates, causing frustration to her. The Ombudsman contacted the Practice and it agreed to complete the following actions within 8 weeks: apologise to Mrs A for the delay in responding to her complaint, explain the reasons for the delay, issue the complaint response and pay Mrs A £250 in recognition of the significant delay, the failure to provide meaningful updates and for the time and trouble in making her complaint. The Ombudsman accepted the above actions as an alternative to a formal investigation.

Ms B complained to the Ombudsman that she had not received a response from a Pharmacy in the area of Swansea Bay University Health Board (“the Pharmacy”) to a complaint that she had made to it regarding its prescription and home delivery service. The Ombudsman found that Mrs B had not received a formal response from the Pharmacy. The Ombudsman contacted the Pharmacy and in resolution of Ms B’s complaint it agreed to, within 20 working days, to apologise to Ms B for the failure to process her complaint and investigate and respond to her complaint in writing.

Mr A complained about the lack of records of an incident when his father sustained a severe fracture during his admission in February 2022 to a mental health facility. The Ombudsman was concerned that inadequacies in the record keeping, which were against routine practice and the principles of good administration, meant Mr A had not been provided with an accurate description of what happened and his complaint could not be satisfactorily addressed. This had led to uncertainty which would result in an ongoing injustice to Mr A. The Ombudsman sought and obtained the Health Board’s agreement to, within 1 month, provide a formal apology for the record keeping failings, offer a payment of £500 in recognition of the lasting uncertainty caused and to remind staff of the importance of accurate record keeping, particularly in cases where patients, who are under assessment for mental health issues, may not be able to later recall information about such incidents.

In 2019 Ms A had a laparoscopic sleeve gastrectomy (a surgical weight loss procedure) at Singleton Hospital. Ms A subsequently complained of dizziness, food becoming stuck in the oesophagus and reflux. Ms A complained that during a telephone consultation on 16 November 2021 the food that she could not eat was not considered, and that she was not referred for a manometry test (to measure the pressure in the gullet and the valve separating the stomach and oesophagus). Ms A also complained that since 4 January 2022 she had no contact with the Bariatric Services. The Ombudsman found before the 16 November 2021 consultation, a list of food that Ms A was intolerant of had been forwarded by a dietitian and nurse to the Consultant and these would have been considered. She also found that whilst delayed, Ms A was referred for a manometry test. While the referral was delayed it had not led to an injustice for Ms A. The Ombudsman found that there was no clinical record/letter of this consultation and on that basis only, this aspect of the complaint was upheld. The Ombudsman also found that the contact Ms A received until 4 January 2022 was appropriate. She found that post bariatric surgical guidance advocates regular patient follow-up for up to 2 years, and that Ms A was followed up for nearly 3 years. This aspect of the complaint was not upheld. The Health Board agreed to implement the Ombudsman’s recommendations within 1 month: apologise to Ms A for the failing and to highlight to relevant staff the importance of maintaining clinical letters/records for all consultations.

Mrs A complained about the care and treatment provided to her husband. In particular that his hospital discharge was unsafe and reference in medical records to palliative care was unexplained. The Ombudsman found that the Health Board’s response to the complaint was delayed and not fulsome. As she considered that this caused injustice to Mrs A, the Health Board agreed to offer a time and trouble payment. It also agreed to reconsider the complaint and provide a response to Mrs A within 6 weeks.

Mr A’s complaint centred on his late father’s management and care during his inpatient hospital admission including the management of the wounds that developed between his toes. The Ombudsman in terms of pressure sore/wound management identified areas, especially around documentation, where shortcomings were evident and improvements could be made. As part of the settlement of Mr A’s complaint the Health Board agreed to carry out a number of actions including apologising to Mr A and the family for the failings identified. It was also asked to ensure that wound assessment charts clearly identified each wound being managed and that any discussion/plan and rationale regarding tissue viability management were documented in patients’ records. Finally, the Health Board should ensure any discharge documentation referred to the management and plan of any identified wounds.

Mrs X complained that Swansea Bay University Health Board had failed to provide a response to the complaint she made to it in October 2022. The Ombudsman decided that the Health Board had failed to provide Mrs X with a response to her complaint in compliance with the Putting Things Right concerns handling procedure, which caused frustration to Mrs 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 3 weeks. It also agreed to apologise for the delay and pay Mrs X financial redress of £250 in recognition of the delay and need to approach the Ombudsman.

Ms A’s complaint related to the care and treatment that she received from the Health Board’s Dermatology Department in 2021. Specifically, she complained that the Health Board failed to properly investigate and diagnose the cause of her hair loss and skin problems, and that it also failed to provide appropriate treatment for these symptoms. The Ombudsman concluded that Ms A’s symptoms had been appropriately investigated, managed and diagnosed by the Health Board. In this respect, although the Health Board’s dermatologists had considered Ms A’s concerns about the cause of her symptoms, the Health Board’s eventual working diagnosis of telogen effluvium (telogen effluvium occurs when there is a marked increase in the number of hairs shed each day) was reasonable. The investigation also found no evidence to suggest that the Health Board had failed to provide appropriate treatment for Ms A’s symptoms. As a result, the Ombudsman did not uphold the complaint.

Mrs D complained that SA1 Medical Centre failed to process her prescriptions and that her complaint had not been answered. The Ombudsman found that the Centre had no record of the complaint which was sent by email to the correct address. She said this caused additional frustration to Mrs D. The Ombudsman decided to settlement the complaint without an investigation and sought the Centre’s agreement to formally log the complaint and respond directly to Mrs D.

Ms L complained that Swansea University Health Board failed to address her concerns in relation to mental health. Ms L further complained that despite raising concerns in December 2022, she had not yet received a response. The Ombudsman found that the Health Board failed to act in accordance with its statutory complaints procedure and failed to provide Ms L with an update on its investigation. She said this caused further frustration to Ms L and concluded that there had been poor complaints handling. As an alternative to an investigation, the Ombudsman sought and gained the Health Board’s agreement to meet with Ms L, provide a complaint response, and issue an ex-gratia payment of £250 for poor complaints handling, within 3 months.

Ms A complained about the standard of treatment provided to her by Swansea Bay University Health Board’s (“the Health Board”) Community Mental Health Team (“CMHT”). In particular, Ms A said that the Health Board failed to: • Provide regular home appointments for depot injections (for slow-release administration of antipsychotic drugs) after May 2021. • Provide support and monitoring when she had to stop taking her regular lithium medication (a drug for treatment of mood disorders) in December 2021. • Identify and act on matters raised at physical health checks. The Ombudsman found that there were shortcomings in the care provided to Ms A. Her care plan clearly identified regular home visits for injections, and these were not always arranged in advance and sometimes did not occur. She also noted that the support and monitoring provided to Ms A when she was advised to stop taking lithium was not adequate, and Ms A’s mental health was not monitored. Both these aspects of the complaint were upheld. The Ombudsman did not identify any failings in relation to the physical health checks and did not uphold this aspect of the complaint. The Ombudsman also noted that some significant clinical entries were made in the handwritten records and not recorded on the CMHT electronic system. Therefore clinically significant decisions and changes were not accessible by all clinicians involved in a patient’s care. Please Note: Summaries are prepared for all reports issued by the Ombudsman. This summary may be displayed on the Ombudsman’s website and may be included in publications issued by the Ombudsman and/or in other media. If you wish to discuss the use of this summary please contact the Ombudsman’s office. The Ombudsman recommended that the Health Board should (within 1 month) apologise in writing to Ms A for the identified shortcomings in her care. She further recommended that the Health Board should (within 3 months): • Ensure that all relevant CMHT clinic entries and prescribing

The Ombudsman investigated Mr L’s complaint that Hywel Dda University Health Board (“the First Health Board”) and Swansea Bay University Health Board (“the Second Health Board”) failed to monitor his late wife, Mrs L’s, bowel problems appropriately; to fully investigate and treat the cause of her raised infection markers promptly; and to refer her for another scan promptly and appropriately when her symptoms escalated. The investigation also considered whether the First Health Board monitored Mrs L’s arterial cannula (a thin tube inserted into the artery to enable continuous measuring of blood pressure) appropriately and took action promptly to address ischaemia (restriction of blood supply to tissue) when it developed during her final hospital admission. The Ombudsman found that Mrs L’s bowel problems were investigated and treated appropriately, and that in the circumstances, follow up monitoring was not necessary after her initial discharge from hospital. There were several possible reasons for Mrs L’s inflammatory markers being raised, and the Ombudsman did not identify any failings by the First and Second Health Boards in investigating and treating the cause. She also found that when Mrs L’s symptoms escalated she was promptly and appropriately referred for a scan. The Ombudsman did not uphold these aspects of the complaint. The Ombudsman found that it was necessary for Mrs L to be fitted with an arterial cannula when she was undergoing major surgery, and that when her ischaemic hand was brought to the attention of medical staff, appropriate action was taken. However, the First Health Board’s monitoring of the arterial cannula fell short of the expected requirements. Whilst the Ombudsman could not say with any certainty that Mrs L’s ischaemic hand would have come to light earlier if it had been appropriately monitored, it is possible that it would. The Ombudsman considered it likely, on the balance of probabilities, that it was Mr L who brought the issue to the

The Ombudsman investigated Mr L’s complaint that Hywel Dda University Health Board (“the First Health Board”) and Swansea Bay University Health Board (“the Second Health Board”) failed to monitor his late wife, Mrs L’s, bowel problems appropriately; to fully investigate and treat the cause of her raised infection markers promptly; and to refer her for another scan promptly and appropriately when her symptoms escalated. The investigation also considered whether the First Health Board monitored Mrs L’s arterial cannula (a thin tube inserted into the artery to enable continuous measuring of blood pressure) appropriately and took action promptly to address ischaemia (restriction of blood supply to tissue) when it developed during her final hospital admission. The Ombudsman found that Mrs L’s bowel problems were investigated and treated appropriately, and that in the circumstances, follow up monitoring was not necessary after her initial discharge from hospital. There were several possible reasons for Mrs L’s inflammatory markers being raised, and the Ombudsman did not identify any failings by the First and Second Health Boards in investigating and treating the cause. She also found that when Mrs L’s symptoms escalated she was promptly and appropriately referred for a scan. The Ombudsman did not uphold these aspects of the complaint. The Ombudsman found that it was necessary for Mrs L to be fitted with an arterial cannula when she was undergoing major surgery, and that when her ischaemic hand was brought to the attention of medical staff, appropriate action was taken. However, the First Health Board’s monitoring of the arterial cannula fell short of the expected requirements. Whilst the Ombudsman could not say with any certainty that Mrs L’s ischaemic hand would have come to light earlier if it had been appropriately monitored, it is possible that it would. The Ombudsman considered it likely, on the balance of probabilities, that it was Mr L who brought the issue to the

Mrs D complained that repeat or additional scans should have been carried out sooner and that her prescription of blood thinners was not reviewed following the outcome of the Computerised Tomography Pulmonary Angiogram (“CTPA,” a scan that looks for blood clots in the lungs). Additionally, the nursing care she received fell below a reasonable standard and she did not receive a catheter (a tube that is inserted into the bladder, allowing urine to drain freely), despite her request for this procedure. Finally, mental health support was not offered or arranged. Mrs D subsequently decided to pursue an Alternative Legal Remedy and so the Ombudsman’s investigation into her complaint was discontinued. As no findings were made, the Ombudsman did not make any recommendations regarding this complaint.

Mrs C complained that the Surgery had failed to respond to the complaint she made in August 2022 and had not provided her with a copy of a call recording she had requested. The Ombudsman decided that there had been a significant delay by the Surgery to respond to the complaint and request for the call recording. She said this caused inconvenience and frustration for Mrs C. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the agreement of the Surgery to apologise to Mrs C and provide her with £50 redress for the failure to respond to her complaint. The Surgery also agreed to provide Mrs C with a complaint response and copy of the call recording within 3 weeks.

Miss X complained that Swansea Bay University Health Board had failed to respond to her complaint submitted in June 2022. The Ombudsman decided that there had been a substantial delay in the Health Board’s complaint response, which led Miss X to contact the Ombudsman. She said this caused frustration to Miss X and decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to issue its complaint response and apologise for the delay within 2 weeks. It also agreed to pay Miss X financial redress of £500 in recognition of the time and trouble expended and the need to approach the Ombudsman.

Ms A complained about the decision of the Surgery to remove her name from its patient list without warning. The assessment found that there was insufficient evidence that the decision to remove Ms A from the list was taken properly. In particular, the Surgery did not appear to have documented its decision not to issue a warning or the decision making on the removal. The Ombudsman found that there was likely to have been uncertainty and distress caused to Ms A, as a result of the Surgery’s decision to remove her name from the patient list. Accordingly, the Ombudsman sought and gained the Surgery’s agreement to provide a written apology. The Surgery also agreed to revise its policy in line with relevant guidance and legislation, to issue and record a warning to patients and to properly document its decision to remove a patient’s name from its list. The Surgery agreed to take these actions within a 30 working day period.

Mr A complained that he was not informed of his positive COVID-19 test or provided with appropriate discharge advice about self-isoaltion. The Ombudsman was concerned that Swansea Bay University Health Board (“the Health Board”) could not satisfactorily evidence whether Mr A was informed about the positive test or provided with information and advice about the self-isolation period, in accordance with its ward policy at the time. She sought and obtained the Health Board’s agreement to, within 1 month, provide Mr A with an apology and a payment of £750 in recognition of these failings. This action was accepted as an alternative to an investigation.

Mrs B complained about the mental health care and treatment provided by Swansea Bay University Health Board to her husband, Mr C, between October 2020 and October 2021. Specifically, the investigation considered complaints that the Health Board failed to: a) Provide appropriate psychiatric review, particularly in response to GP referrals in the summer of 2021. b) Provide appropriate review and support in relation to Mr C’s medication regime. c) Make adequate arrangements to support Mr C’s mental health needs. d) Respond adequately to the concerns raised by Mrs B. The investigation found that the Health Board failed to provide an appropriate psychiatric review in June and July 2021 in response to concerns raised by 2 GPs and Mrs B. It was likely that the failure to provide the expected level of care was a significant contributory factor in the deterioration of Mr C’s mental health to the point where he took 2 intentional medication overdoses in late July 2021. Accordingly, the Ombudsman upheld this complaint. The investigation found that while Mr C had received appropriate medication reviews and support, he had not been informed of the outcome of relevant discussions as promised. To that limited extent, the second complaint was upheld. The investigation found that, following the decision to transfer Mr C to a different community mental health team, there was a failure to provide appropriate regular support. Accordingly, the Ombudsman upheld the third complaint. The Ombudsman also upheld the fourth complaint on the grounds that the Health Board’s response to Mrs B’s complaint was not adequate. The Ombudsman recommended that the Health Board should apologise for the failings identified and make a financial redress payment of £1,250 for the injustices caused to Mrs B and Mr C. The Ombudsman also recommended that the Health Board should discuss this report at an appropriate clinical governance meeting and update its policies to ensure that transfers of care between its c

Mrs L complained that despite raising concerns in December 2022 about her daughter’s treatment and care at Swansea Bay University, the Health Board had failed to provide her with a response. The Ombudsman concluded that the Health Board had failed to act in accordance with its statutory complaints procedure and failed to keep Mrs L updated with its investigation. She said this caused Mrs L frustration. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to provide Mrs L with an apology and a complaint response within 30 working days.

Mrs G complained that Swansea Bay University Health Board failed to provide appropriate care and treatment for her mother’s cancer. The Ombudsman’s investigation found that while the clinical approach to diagnosing the cancer affecting Mrs G’s mother, Mrs O, was within the range of appropriate practice, there was an avoidable delay by the relevant Multidisciplinary Team (“the MDT”) in carrying out necessary investigations. This delayed the point at which surgery was attempted, following which Mrs O was informed that the cancer was not curable. While earlier treatment would, sadly, not have altered the course of Mrs O’s cancer, the delay prolonged the uncertainty for her and her family at a time when they were understandably anxious for clear information. The investigation also found that there was a 4-6 week delay in providing Mrs O with a chemotherapy appointment after the surgery. This further delay would have caused additional distress and anxiety for Mrs O and her family. Accordingly, the Ombudsman upheld the complaint. The Ombudsman recommended that the Health Board make a fulsome apology to Mrs G and her family for the delay in diagnosing and treating Mrs O’s cancer. She also recommended that the Health Board should ensure that the findings of the report are considered by a relevant clinical governance forum to agree specific actions to ensure that: • the MDT arranges investigations and procedures in a timely manner • where clinical findings suggest that a palliative oncology referral is appropriate, an immediate referral is made without waiting for MDT approval.

Mr L complained that despite raising concerns with Swansea Bay University Health Board in May 2022 about his father’s treatment, he had not yet received a response. The Ombudsman found that the Health Board failed to act in accordance with its statutory complaint’s procedure, and said this caused frustration to Mr L. As an alternative to an investigation, the Ombudsman sought and gained the Health Board’s agreement to provide Mr L with an apology, a full response, and a time and trouble payment of £250 within 30 working days.

Mr E complained about the healthcare staff’s behaviour towards him and the visiting restrictions placed on him during his wife’s inpatient admission. He also complained about aspects of his wife’s care which included nursing care. In addition, he was dissatisfied with the process that had led to his wife being discharged into a care home and the Health Board’s handling of his complaint. The Ombudsman discontinued the investigation as the court proceedings Mr E had taken meant he had exercised an alternative legal remedy (“ALR”). The limitations that apply under the legislation that gives the Ombudsman her powers meant she could no longer investigate the complaint. Based on the court findings the Ombudsman also concluded that the parts of Mr E’s complaint relating to his wife’s care should also be discontinued. Finally, the Ombudsman concluded that even if the ALR did not apply to the complaint handling issues Mr E had raised, it was not proportionate to continue the investigation into those matters on their own.

Miss S complained about Swansea Bay University Health Board’s handling of her complaint about the delay in providing her with treatment. The Ombudsman decided that whilst the Health Board has been providing regular and meaningful updates to Miss S it had not issued its complaint response. She said that this caused frustration and uncertainty to Miss S. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to provide an apology for the continued delay, offer her redress of £250 and issue a complaint response within 6 weeks.

Mrs F complained to the Ombudsman (via her Community Health Council advocate) about the GP’s action in respect of wrong information in her medical record. She also had concerns with test results, x-rays and referrals, as well as errors with her medication. The Ombudsman found that the GP’s actions were sufficient in respect of concerns around test results, x-rays and referrals. The Ombudsman also found that the action taken by the GP to resolve errors with her medication was proportionate. However, the Ombudsman was concerned that whilst action to correct Mrs F’s medical record was ongoing, and that a meeting had taken place regarding this, the inaccuracies were still not resolved. The Ombudsman sought and gained the GP’s agreement to review Mrs F’s medical records to ensure that all information is rectified, to provide Mrs F with the revised records to review and, if necessary, arrange a further meeting to discuss identified discrepancies, within 20 working days.