PSOW Individual Decisions

Mr A complained that Hywel Dda University Health Board failed to respond to the complaint he submitted regarding an appointment he was not made aware of. The Ombudsman found that, while the Health Board had responded as an enquiry, it could have provided more information to Mr A. The Ombudsman said this caused uncertainty and frustration for Mr A and decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to, within 4 weeks, provide a full complaint response, apologise for the delay and for not including all the information and explain why this happened.

Mrs A complained about the Health Board’s management of her father, Mr C’s, pancreatitis (an inflammatory condition of the pancreas) and subsequent diagnosis of pancreatic cancer. The investigation focused only on whether Mr C received appropriate medical management and intervention between January 2023 and January 2024, relating to his pancreatitis; whether Mr C’s pancreatic cancer should have been investigated and diagnosed earlier; whether appropriate treatment was provided to Mr C following his diagnosis of pancreatic cancer; and, whether an appropriate palliative care plan was put in place, and implemented for Mr C. The investigation found that Mr C’s management before and after his cancer diagnosis was clinically appropriate and there were no missed opportunities to diagnose pancreatic cancer sooner. Whilst Mr C’s presentation included symptoms which were similar to pancreatic cancer, appropriate and extensive investigations did not identify cancer during 2023, with the possibility of pancreatic cancer identified only in early 2024. However, there were shortcomings in the level of service Mr C received from the dietetics service due to limited documentation to evidence appropriate actions. In addition, there were also communication shortcomings due to a disconnect in communication which meant a lack of clarity for the family about Mr C’s management. Complaints a) and b) were upheld to this limited extent. The investigation found when Mr C received a formal diagnosis of cancer, it was metastatic and incurable and therefore the recommendation for palliative chemotherapy was the correct management plan. In terms of dietetic service involvement, the community dietetic team made an appropriate referral/handover to the hospital dietetic service in February 2024 due to Mr C’s hospital admission. According to acute nutrition support standards, the earliest the hospital dietetic team would have seen Mr C was the day before he died. However, had they seen him as planned

Mr A complained that Hywel Dda University Health Board failed to respond to the complaint he submitted in July 2025. The Ombudsman found that the Health Board failed to provide Mr A with a final complaint response. The Ombudsman said this caused uncertainty and frustration for Mr A and decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to, within 6 weeks, provide a final complaint response, apologise for the delay and explain why this happened, and offer a £100 financial redress payment in recognition of the delays.

Mrs L complained about the care provided to her late brother, Mr M. We investigated concerns about whether opportunities were missed to make an earlier diagnosis of pulmonary embolism (a blocked blood vessel in the lungs) and whether Mr M’s treatment after diagnosis of a pulmonary embolism was appropriate, timely and in keeping with relevant guidance. The investigation found that despite Mr M’s presentation giving reason to consider a diagnosis of pulmonary embolism, relevant tests were not conducted. This was a failing and an injustice to Mrs L who will be left with uncertainty regarding what the outcome may have been had these tests been conducted. This part of Mrs L’s complaint was upheld. Once pulmonary embolism was diagnosed, Mr M’s clinical management was appropriate and treatment was carefully considered and risk assessed in light of his complex condition. This part of Mrs L’s complaint was not upheld. The Health Board agreed to apologise to Mrs L and offer her financial redress of £750 in recognition of the distress caused by the uncertainty she will be left with. It also agreed to ensure that the clinicians that treated Mr M during his first admission to the Hospital are familiar with the symptoms of pulmonary embolism, particularly in patients with pre-existing lung conditions.

Ms D complained about the standard of care provided to her late mother, Mrs E, by the GP Practice. Ms D complained that, following a home visit in April 2025, the GP did not arrange Mrs E’s admission to hospital. The Ombudsman’s investigation considered the clinical assessment of Mrs E at the home visit, and the action taken as a result of that assessment, including the decision not to arrange Mrs E’s admission to hospital. The Ombudsman found that the clinical assessment of Mrs E during the home visit was appropriate. However, the recording of the clinical findings should have been more detailed. This aspect of the complaint was therefore partly upheld, limited to the associated record keeping. The Ombudsman concluded that the decision not to arrange emergency admission to hospital for Mrs E was not unreasonable or outside of accepted clinical practice. This aspect of the complaint was not upheld.

Ms A complained about the standard of care provided to her late father, Mr B, when he was admitted to hospital in February 2024 due to swallowing issues. The Ombudsman’s investigation considered whether, during Mr B’s inpatient stay on an ENT ward, appropriate medical care and interventions were provided in a timely manner. The Ombudsman found that the medical care, and the Gastroenterology investigations and procedures which were carried out, were all reasonable to address Mr B’s clinical presentation and symptoms. There was a delay in the initial Gastroenterology review, and the subsequent transfer to a Gastroenterology ward. However, the Ombudsman found that this did not affect Mr B’s medical management, the treatment options that were open to him, or the outcome of that treatment. The complaint was therefore not upheld.

Ms A complained that Hywel Dda University Health Board failed to respond to the complaint she submitted in May 2025. The Ombudsman found that the Health Board failed to provide Ms A with a final complaint response. The Ombudsman said this caused uncertainty and frustration for Ms A and decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to, within 7 weeks, issue the final complaint response, apologise and provide an explanation for the delay, and offer £150 redress payment in recognition of the delays.

Ms F complained about the care provided to her son, Mr G, in February 2024. We investigated her concerns about the clinical assessment and treatment of Mr G’s physical symptoms, his management while he was in hospital and the standard of record keeping during the relevant time period. The Ombudsman found that the clinical care provided and the working diagnoses as the clinical picture unfolded were, overall, appropriate. There was nothing to suggest Mr G’s Influenza A should have been identified sooner and it was treated promptly when it was diagnosed. Additionally, although there were gaps and omissions in the record keeping, these did not compromise Mr G’s care to the extent that it was inappropriate. These elements of Mrs F’s complaint were not upheld. The Ombudsman also found that Mr G was managed in a chair, rather than a bed. This was in line with relevant policy for when the hospital is under pressure with high capacity but there was a failure in this case to consider Mr G’s autism and individual needs in relation to the decision to manage his care in a chair rather than a bed. This element of the complaint was upheld. Since the time of the events, the Health Board had taken significant positive steps to improve the experiences of patients with additional needs. The Ombudsman invited the Health Board to remind staff of the importance of maintaining comprehensive records – including at times of high pressure – to ensure continuity of care. The Ombudsman recommended that the Health Board should apologise to Mr G, remind relevant staff of the importance of taking full account of patients’ additional needs, including at times of extreme pressure, and ensure that an appropriate proportion of relevant staff had completed approved Autism Awareness training.

Mrs C complained that Hywel Dda University Health Board (“the Health Board”) asked her and her son inappropriate questions as part of an ADHD assessment, which caused them unnecessary distress. The Ombudsman recognised the concern that the questions had caused, but decided that the use of the questionnaires was consistent with National Guidelines and had been used appropriately. However, the Ombudsman found that there were errors in the complaints response, which wrongly suggested that Mrs C had asked her son to complete the wrong form. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to write to Mrs C within 4 weeks to apologise for the incorrect information in the complaint response, and for suggesting that Mrs C had made an error, when she had not.

Mrs C complained about whether the standard of care provided to her mother, Mrs B, for the management of her cataract (when the lens in the eye develops a cloudy patch) to her right eye was clinically appropriate and timely. The investigation found that Hywel Dda University Health Board (“the Health Board”) did not respond appropriately to advice it requested from a Second Health Board regarding Mrs B’s care. During the COVID-19 pandemic when public health measures which were put in place to prevent the spread of infection I have seen no evidence that the Health Board considered guidance in place at the time to assess the risk this would cause to Mrs B. When Mrs B was seen again, following the easing of these measures, the review she underwent was inadequate. Relevant tests were not undertaken, a letter to her GP regarding medication was insufficiently detailed and an opportunity was missed to make an earlier referral for further treatment. During the period of time under investigation Mrs B experienced numerous cancelled clinic appointments. These are significant service failings. Mrs B, who is blind in her left eye, is now also significantly sight impaired in her right eye. Mrs C has described the devastating impact this has had on both Mrs B and her wider family. I also consider that the failures in this case are ones from which other health boards can learn. I have seen no evidence the Health Board assessed the potential harm to Mrs B when cancelling clinic appointments. Earlier opportunities to identify the seriousness of Mrs B’s condition, and to refer her for further treatment, were also missed. The Ombudsman made a number of recommendations which the Health Board accepted: Within 1 month: a) Apologise to Mrs B and Mrs C for the failings identified in this report. b) Offer Mrs B financial redress in the sum of £4,500 reflecting the serious failings I have found and the resulting and lasting significant impact upon her. To further offer Mrs B redress of £300 f

Mr A complained about the care and treatment provided to him by the Health Board from March to September 2024 and about the response to his complaint. The Ombudsman found that, although the Health Board had responded to Mr A’s complaint, it had not provided him with clear information regarding communication tools available to support patients. The Ombudsman contacted the Health Board, which agreed to undertake the following actions to resolve the complaint and as an alternative to a formal investigation. The Ombudsman sought and gained the Health Board’s agreement to provide Mr A with an explanation and information about available communication tools, such as the patient passport, to support patients when accessing healthcare. The Health Board agreed to do this within 4 weeks.

Mrs B complained about the discharge planning in respect of her daughter, Miss A. The investigation considered whether the discharge planning prior to Miss A’s discharge on 23 January 2023 was appropriate and met her needs. The investigation specifically considered whether an updated risk assessment and care and treatment plan (“CTP”) were required prior to discharge and whether there were controlled measures in place to ensure mitigation of the risks identified. Miss A had been re-admitted to hospital on 21 January 2023 following an overdose. The planning in the lead up to her previous discharge in December 2022 was clinically appropriate. The Wales Applied Risk Research Network (“WARRN”) formulation-based assessment and CTP undertaken on 22 December was comprehensive, extensive and in line with national guidance. These assessments and plans were of a high standard. The WARRN was updated on 2 occasions during the appropriately short re-admission in January. Whilst the CTP was not updated by the Community Mental Health Team (“CMHT”) prior to discharge, the December 2022 version of the CTP covered a wide range of scenarios and recommendations on how to deal with them. There was a risk that Miss A would attempt to self-harm post discharge. However, a certain degree of risk is commonly accepted to allow patients to live in the community and avoid long term hospital admission. The management plan to mitigate the risk of self-harm/suicide by locking Miss A’s medication in a cabinet was clinically appropriate and in line with national guidance. Unfortunately, the medication cabinet was not robust enough to withstand force, but this was not the fault of the Health Board. The complaint was not upheld.

Ms A complained that the Health Board’s complaint response failed to address all her points, lacked detail and explanation and did not inform her of the next steps regarding her treatment. The Ombudsman found that the complaint response lacked detail. The Ombudsman said this left Ms A with many unanswered questions and decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to within 30 working days issue a further complaint response addressing and explaining the points Ms A raised.

Ms A complained about the care and treatment her father received from Hywel Dda University Health Board when he was an inpatient in Withybush Hospital prior to his sad death in 2023. Ms A complained that her father was given a dry potassium tablet which should have been dissolved in water, and following this he became unwell. The Ombudsman acknowledged the Health Board’s position that the incident was not recorded in the medical records, and if it had occurred it would have been documented. However, it was also noted that Ms A had her own contemporaneous diary entries. The Ombudsman decided that whilst it was not possible to determine what had occurred, if the incident had taken place there was potential learning for the Health Board. She decided to settle the complaint without an investigation. Within 1 month, remind the staff on the ward of the importance of ensuring that the potassium tablets are administered with water and write to Ms A to inform her of this action.

Mr A complained that he had not received a response from Hywel Dda University Health Board to a complaint he made in February 2025 about a head injury. The Ombudsman found that the Health Board had not provided Mr A with a final complaint response. The Ombudsman said this caused uncertainty and frustration for Mr A and decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to provide the final complaint response that will include an apology and explanation for the delays. The Health Board agreed to do this within 4 weeks of the Ombudsman’s decision.

Mrs C complained that Hywel Dda University Health Board had failed to arrange a face-to-face meeting regarding the treatment and care her late mother had received. The Ombudsman found that Mrs C had complained to the Health Board 7 months ago and had still not received a formal complaint response. The Ombudsman said this left many unanswered questions for Mrs C and decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to, within 4 weeks, apologise for the delay and issue a complaint response to Mrs C as a meeting has taken place already.

Mrs H complained that Hywel Dda University Health Board failed to issue a response to her complaint which, she made to it in May 2025. The Ombudsman found that whilst the Health Board had not provided a response to Mrs H’s complaint at the time of her complaint to this office, it had subsequently issued a response. She said that this caused frustration to Mrs H. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to apologise and provide an explanation to Mrs H for the delay, and offer £75 redress in recognition of her time and trouble in making her complaint to the Ombudsman within 3 weeks.

Mr A complained that he has not received a response from Hywel Dda University Health Board in respect of events that occurred when his son very sadly passed away. The Ombudsman decided that whilst there had been some delays which were outside of the Health Board’s control, these had been resolved and Mr A had to be provided with an update and a timeframe within which he would receive the report. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement that within 1 month it would update Mr A on the progress of the investigation and that this would be shared with him by the end of February 2026.

Ms G complained that Hywel Dda University Health Board failed to issue a response to her complaint, which she made to it in April 2025, regarding the care and treatment provided to her late partner. The Ombudsman found that the Health Board had failed to issue a complaint response. She said this caused frustration and uncertainty to Ms G. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to apologise and provide an explanation to Ms G for the delay, issue a complaint response, and offer a redress payment of £100 in recognition of her time and trouble in making a complaint to the Ombudsman.

Mr B complained, via an advocate, about a lack of complaint responses and about various aspects of the care and treatment provided to his wife, Mrs B, by a GP Practice in the Hywel Dda University Health Board area. The Ombudsman considered that Mr B had not had a full response to his complaints made in January and July 2025, which was an injustice. The Ombudsman contacted the Practice, which agreed to undertake the following actions to resolve the complaint. The Practice agreed that within 4 weeks, and in line with the Putting Things Right arrangements, it would investigate and respond fully and clearly to the concerns Mr B raised about it, with explanations of findings and outcomes set out in a manner appropriate for a layperson. The Ombudsman therefore decided to settle the complaint without investigation.

Ms A complained about the Health Board’s communication with her about a shoulder operation. She said that she had only later been told that she had suffered a punctured lung. It did not appear from information considered during the assessment that Ms A had suffered a punctured lung. However, the Ombudsman decided that the Health Board’s communication with Ms A could have been clearer. She decided to settle the complaint without an investigation. The agreement of the Health Board was sought and gained to take the following action within 3 months: – Arrange a meeting with Ms A and her advocate and relevant clinicians to explain events that took place during and after the shoulder operation.

Mrs A complained that the Health Board had failed to respond to a complaint she had submitted to it in February 2025. The Ombudsman found that the Health Board failed to investigate the complaint within the relevant timescale which caused additional frustration and uncertainty for Mrs A. The Ombudsman decided to settle the complaint without a formal investigation. The Ombudsman sought and gained the Health Board’s agreement to provide an explanation and apology to Mrs A for the delay in responding to the complaint and to issue its complaint response within one month.

Mrs A complained that the Health Board failed to fully address the concerns raised in her complaint to it. The Ombudsman found that the Health Board failed to respond to all the concerns raised within the complaint and this caused additional frustration, concern and uncertainty for Mrs A. The Ombudsman sought and gained the Health Board’s agreement to provide an apology to Mrs A for not fully addressing her concerns and to issue a comprehensive complaint response within one month.

Mr A complained that the Health Board failed to identify a lesion in his right kidney from a CT scan in April 2016. The investigation found that the Health Board’s interpretation of Mr A’s CT scan from April 2016 reached an appropriate level. The complaint was therefore not upheld.

The Ombudsman’s investigation centred on the care and treatment Mrs A’s daughter, Child B, received from Glangwili General Hospital (the Hospital) in November 2023 when she presented with symptoms of right-sided pain, pain behind her right eye and vomiting. Specifically, we considered: • Whether the Hospital provided Child B with appropriate pain relief. • Whether clinicians fully recognised the seriousness of Child B’s symptoms and whether she should have had an MRI scan sooner. The Ombudsman found that the Hospital had provided appropriate pain relief to Child B, based on her clinical presentation and that the MRI scan was timely. Mrs A’s complaint was not upheld. The investigation identified points of learning (primarily around documentation and clinical thinking) which the Health Board was invited to consider.