PSOW Individual Decisions

Mrs A complained that the Health Board did not take seriously and/or properly progress referrals from her GP, regarding a facial lesion which was diagnosed as being cancerous in May 2024. The investigation focused specifically on whether the Health Board’s assessment of Mrs A’s facial lesion and the GP referrals between August 2020 and September 2023 were clinically appropriate. The investigation found that the initial management of Mrs A’s lesion in 2020/21 and discharge from the Dermatology service was clinically appropriate. The investigation also found that, whilst the images shared by Mrs A’s GP with the Dermatology service in September 2023 did not indicate the classical features of nodular basal cell carcinoma (“BCC” – the most common type of skin cancer), they were clinically suggestive of a less common type of BCC which required further assessment. On this basis, following the GP referrals, either a request for additional images with a dermoscope (examination of skin conditions using a dermoscope – a specialised device that magnifies the skin surface) or a face-to-face appointment should have taken place. Rejecting the referrals without any further assessment represented a service failure. As BCC is a slow growing tumour, it is unlikely to have spread much during the investigation timeframe. Therefore, earlier assessment would not necessarily have altered the treatment Mrs A received or the outcome of that treatment, although there remains a possibility that it may have. This left Mrs A with the uncertainty that earlier review and investigations might have made some difference. The complaint was upheld to this extent. The Health Board agreed to apologise to Mrs A for the identified failings, to share the report for learning with the relevant clinicians and to review Mrs A’s images at a Dermatology service meeting to identify learning.

Ms F complained about the care her partner, Mr E, received from Swansea Bay University Health Board (“the Health Board”). The Ombudsman investigated whether appropriate examination and investigations were undertaken of Mr E’s symptoms when he presented at the Out-of-Hours (“OOH”) GP service on 13 April 2025. The investigation found that the assessment of Mr E’s condition and the resulting plan of care was appropriate in the circumstances. The OOH GP who reviewed Mr E, gathered relevant information and formed a clinically appropriate management plan for him to continue with pain relief, as required, and to see his own GP for follow-up. The Ombudsman did not uphold the complaint.

Mrs B was concerned that, despite her husband, Mr B, experiencing significant pain in his abdomen and ribs in 2024, clinicians at the GP Practice missed signs of lung cancer symptoms, resulting in a delay in the diagnosis of his cancer. The investigation focused on whether clinicians at the GP Practice acted appropriately when Mr B presented with pain in his abdomen and ribs between July and August 2024. The investigation found that at each of the consultations between July and August 2024, the examinations, possible diagnoses, treatment and actions of the clinicians were within the range of acceptable clinical practice. There was no indication that Mr B should have been referred for a chest X-ray for possible suspected lung cancer before the end of August. The investigation also found that while clinicians appropriately considered Mr B’s history of prostate cancer, including a normal PSA reading in May 2024, prostate cancer was not the cause of Mr B’s lung cancer. The complaint was not upheld.

Mr S complained about the care and treatment provided to him by Swansea Bay University Health Board and specifically that it unnecessarily delayed his treatment for cancer and exceeded the 62 day suspected cancer to treatment pathway. The Ombudsman found that the Health Board had not fully responded to Mr S’s complaint. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to provide confirmation, within 5 days, to Mr S that his complaint about events that it had not addressed would be fully investigated with in accordance with The National Health Service (Concerns, Complaints and Redress Arrangements) (Wales) Regulations 2011.

Mr B complained about whether hip replacement surgery arranged and funded by Swansea Bay University Health Board (“the Health Board”) and performed at Nuffield Health – The Vale Hospital (“the Private Hospital”) was carried out to an appropriate standard and the subsequent aftercare. The Ombudsman found that the prosthesis used in the hip replacement surgery was under-sized, which carried a known risk of early loosening. Whilst this risk could not be completely eliminated, measures that could have reduced the risk were not taken. This part of Mr B’s complaint was upheld. When Mr B reported concerns following surgery the action taken was appropriate and timely. This part of Mr B’s complaint was not upheld. When Mr B complained to the Health Board he was not told that he should complain directly to the Private Hospital, and whilst a complaint response was issued it did not fully address all of Mr B’s concerns. The Health Board and the Private Hospital both accepted the Ombudsman’s recommendations. The Health Board agreed to apologise to Mr B for the failures in handling his complaint and to ensure that its staff who may deal with complaints about commissioned care, are aware of the correct procedure for doing so. The Private Hospital agreed to apologise to Mr B for its failure to mitigate the risk of the prosthesis failing, and offer him a redress payment of £750 and to share the report with the Surgeon who undertook Mr B’s surgery so the findings can be considered and discussed.

Mr B complained about whether hip replacement surgery arranged and funded by Swansea Bay University Health Board (“the Health Board”) and performed at Nuffield Health – The Vale Hospital (“the Private Hospital”) was carried out to an appropriate standard and the subsequent aftercare. The Ombudsman found that the prosthesis used in the hip replacement surgery was under-sized, which carried a known risk of early loosening. Whilst this risk could not be completely eliminated, measures that could have reduced the risk were not taken. This part of Mr B’s complaint was upheld. When Mr B reported concerns following surgery the action taken was appropriate and timely. This part of Mr B’s complaint was not upheld. When Mr B complained to the Health Board he was not told that he should complain directly to the Private Hospital, and whilst a complaint response was issued it did not fully address all of Mr B’s concerns. The Health Board and the Private Hospital both accepted the Ombudsman’s recommendations. The Health Board agreed to apologise to Mr B for the failures in handling his complaint and to ensure that its staff who may deal with complaints about commissioned care, are aware of the correct procedure for doing so. The Private Hospital agreed to apologise to Mr B for its failure to mitigate the risk of the prosthesis failing, and offer him a redress payment of £750 and to share the report with the Surgeon who undertook Mr B’s surgery so the findings can be considered and discussed.

Mr A complained that Swansea Bay Health Board had failed to respond to his complaint about the treatment and care his father received. The Ombudsman found that Mr A complained to the Health Board 9 months ago and had still not received a formal complaint response. The Ombudsman considered this caused Mr A and his family unanswered questions and decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to issue a full complaint response to Mr A which includes explaining the reasons and apologising for the delay within 4 weeks.

Mrs D complained about the care and treatment provided to her by Swansea Bay University Health Board. The Ombudsman considered whether the investigations conducted by the Health Board into a suspected neuroendocrine tumour (“NET” – a rare form of cancer that affects the cells that release hormones into the bloodstream) were appropriate and timely. The investigation found that the investigations conducted by the Health Board into a suspected NET were appropriate and timely. Although there had been some contradictory findings from tests and procedures that had prolonged the treatment pathway, follow up investigations were clinically appropriate. The investigation found no evidence of unnecessary delays and that Mrs D had been informed of the findings and the plans. The Ombudsman did not uphold the complaint.

Mrs A complained that the Health Board had failed to respond to her complaint and of its lack of communication. The Ombudsman found that the Health Board failed to investigate the complaint within the relevant timescale and it failed to keep Mrs A updated. She said this caused uncertainty and frustration for Mrs A. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to, within 3 weeks, offer an apology and explanation for the delay and lack of communication, issues its complaint response and offer a £100 redress payment.

Mrs A complained that she had not received a complaint response from Swansea Bay University Health Board (“the Health Board”), despite complaining 7 months ago. At assessment, the Ombudsman found that the Health Board had not provided a complaint response to Mrs A. The Health Board agreed, within 4 weeks, to provide a complaint response to Mrs A, including apologies and reasons for delay.

Mr A complained that his place on the waiting list for surgery was reset when he rearranged an appointment. The Ombudsman recognised the language used in the complaint response may have led to confusion. However, as Mr A gave prior notice of his inability to attend a mutually agreed appointment, this was considered a ‘Could Not Attend’ by the Health Board. As per the Revised Rules for Managing Referral to Treatment Waiting Times for Phased Implementation April 2017 (“the Rules”), the Health Board was, therefore, entitled to reset his clock on the waiting list. However, the Ombudsman was concerned that the Health Board had not communicated this to Mr A when rebooking his appointment. The Ombudsman sought and gained the Health Board’s agreement to, within 4 weeks, apologise to Mr A for not communicating that his clock had been reset when rebooking his appointment, and to ensure that all patients are informed of resets to their place on the waiting list going forward, as per the Management of Referral to Treatment Waiting Times Guidance April 2025, which now applies. The Health Board agreed to do so.

The investigation considered whether the dentures provided to Mr A were clinically appropriate, including the advice provided about their longevity. By way of an outcome Mr A wanted the cost of the dentures reimbursed. The Dental Practice agreed as part of a settlement to reimburse Mr A the sum of £260 for the dental treatment it provided in 2025, which included the cost of the dentures. It also said that as part of wider learning the Dental Practice will feed back any points of learning to the Dentist.

Ms B complained about inpatient care and treatment provided to her husband in February 2025, in particular the management of his medication. The assessment found that the complaint response did not adequately address the concerns raised or qualifying liability, further to Welsh Government guidance. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to, within 2 months, fully respond to Ms B’s outstanding concerns, including qualifying liability and offer an apology for not having done so previously.

Mr B complained that Swansea Bay University Health Board failed to respond to his complaint about the care and treatment provided to his mother. The Ombudsman found that the Health Board had failed to provide a response to Mr B’s re-opened complaint. She said that this caused frustration and uncertainty to Mr B. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to write to Mr B with an apology for the delay, offer to pay £75 in recogonition of Mr B’s time and trouble in making his complaint to the Ombudsman and to issue a complaint response within 2 weeks.

Mrs C complained that the Practice failed to provide a response to her complaint about her ill-fitting denture. The Ombudsman found that the Practice had failed to provide a response to Mrs C’s complaint. She said that this caused frustration and uncertainty to Mrs C. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Practice’s agreement to write to Mrs C with an apology and explanation for the delay in issuing a complaint response and for the failure to provide regular and meaningful updates, offer to pay Mrs C £50 in recognition of her time and trouble in making a complaint to the Ombudsman and issue a complaint response within 2 weeks.

Miss A complained that the Health Board had failed to respond to her complaint regarding the treatment and care her late father had received. The Ombudsman found that Miss A complained 10 months ago and had still not received a formal complaint response from the Health Board. The Ombudsman said this left many answered questions for Miss A and decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to apologise and explain the reasons for delay and issue a full complaint response within 7 weeks.

Complainant complained that the Health Board had failed to respond to a complaint he had submitted 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 the complainant. 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 for the delay in responding to the complaint and to issue its complaint response by 30 January 2026.

Mr A complained about the care provided to his wife during a hospital admission in March 2025. Mr A was dissatisfied with the Health Board’s responses tohis complaint. He had raised further concerns about the timeliness of the response, factual inaccuracies and the failure to address all of his concerns. The Ombudsman found that although the Health Board had investigated Mr A’s concerns, he had not received an adequate response to his initial complaint or the matters raised subsequently. Mr A was inconvenienced by the organisation’s actions, and this caused uncertainty and frustration for him. The Ombudsman decided to settle the complaint without an investigation. The Health Board agreed to, within 6 weeks, reconsider Mr A’s complaint and provide him with a further written complaint response, addressing the additional matters raised with the Health Board and the Ombudsman.

Ms A complained about delays by Swansea Bay University Health Board following her mother’s endoscopy and that the response provided to her complaint did not address all her concerns. The Ombudsman found that although the Health Board had conducted an investigation into the complaint, when Ms A contacted it about her outstanding concerns, it did not respond to the points raised. The Ombudsman decided to settle the complaint without investigation. The Ombudsman sought and gained the Health Board’s agreement to apologise to Ms A for not addressing her outstanding concerns and to provide a further written complaint response. The Health Board agreed to do this within 6weeks of the Ombudsman’s decision

Mr A complained that Swansea Bay University Health Board had failed to respond to his complaint regarding the treatment and care his late mother had received. The Ombudsman found that Mr A had complained to the Health Board 11 months ago and had still not received a formal complaint response. The Ombudsman said this caused frustration to Mr A and decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to apologise and explain the reasons for the delay, issue a full complaint response and offer a £100 redress payment to Mr A within 6 weeks.

Mr D complained about the care and treatment provided by Swansea Bay University Health Board to his mother, Mrs E, when diagnosing her endometrial cancer. The Ombudsman considered whether investigations and treatment, carried out between October 2021 and March 2022, were adequate and timely, and whether investigations and treatment, carried out following the urgent suspected cancer (“USC”) referral from the GP in February 2023, were adequate and timely. The Ombudsman upheld both complaints. The investigation found there was a failure to adequately consider and follow up the findings of the histology report in October 2021. This meant that decisions about Mrs E’s care at that time were not informed by reliable clinical information. As a result, she lost the opportunity for better care. The investigation also found that from the point of the USC referral in February 2023, there were unacceptable delays in the investigation of Mrs E’s symptoms. This meant that the diagnosis of Mrs E’s cancer was avoidably delayed for several months. As a result, Mrs E lost the opportunity for earlier intervention and treatment which could have had a significant impact on the options available for the management and treatment of her cancer. The Health Board accepted the Ombudsman’s recommendations, which included an apology and a financial redress payment of £1,000 to Mrs E and a number of service improvement actions aimed at addressing the causes of the delays in her case.

Mr C complained that a GP Practice in the area of Swansea Bay University Health Board (“the Practice”) had not ensured that his father, Mr A’s, prescriptions were processed correctly and in a timely manner. He further complained that the Practice had not handled his complaints in accordance with the NHS (Concerns and Redress Arrangements) (Wales) Regulations 2011 and associated guidance. The Ombudsman found that there had been frequent errors and discrepancies in the way the Practice processed Mr A’s prescriptions over a period of 14 months. The errors caused delays in supplying Mr A with the medical equipment he needed. The standard of record-keeping was poor and hampered the Practice’s effectiveness in monitoring how prescriptions were being processed. The Practice did not have an up-to-date complaints procedure, and it had failed to acknowledge and adequately respond to Mr C’s complaints. The Ombudsman upheld Mr C’s complaints. The Practice agreed to write to Mr C to apologise for the failings identified and take steps to ensure Mr A’s prescriptions were processed correctly in future. It also agreed to carry out an audit of similar cases, review its records management and complaints procedures, and provide training to staff involved in handling complaints.

Mr W complained about a delay in receiving a total knee replacement surgery from Swansea Bay University Health Board, which he had been waiting for since August 2019. The investigation considered whether Mr W’s waiting time for surgery was appropriately managed in line with the Welsh Government’s Rules for Managing Referral to Treatment Waiting Times, specifically when his waiting time clock was re-set in October 2023. The investigation found that Mr W’s waiting time clock was inappropriately re-set in October 2023. It found no evidence that a clinician had documented that Mr W was medically unfit to proceed with surgery. Mr W required a repeat scan, due to the amount of time he had been waiting, which confirmed his fitness to proceed. The decision to re-set the waiting time clock was also not communicated to Mr W and he only became aware when he made a complaint. As a result of the delay, Mr W had experienced pain, reduced mobility and ongoing frustration. Further to this, he is now in a position where he is not able to proceed with surgery and this opportunity has been lost. In January 2024, this office published 3 reports in the public interest in relation to the Health Board’s management of the waiting list for orthopaedic treatment. These reports found that in all 3 cases the complainants had been treated unfairly because of errors in the way the waiting lists for orthopaedic surgery were managed. One of the recommendations contained within those reports was that the Health Board should carry out an audit of its waiting list to establish whether any other errors had been made relating to the resetting of waiting list times or improper removal from the list. It is concerning that further errors have subsequently been found despite this audit having taken place. This raises concern about the reliability of the audit the Health Board undertook previously. The Health Board agreed to the following recommendations: a) Arrange for the Chief Executive to make an apolog

Ms A complained about the length of time it took Swansea Bay University Health Board to respond to a complaint she made to it about the care and treatment her mother, Ms B, received. The Ombudsman decided that whilst a complaint response had been issued, this had taken a long time despite Ms A’s advocate chasing it up the response. This had caused further distress to Ms A and her mother. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement that within 1 month it would make a redress payment of £125 in recognition of the distress caused.

Mrs X complained that Swansea Bay University Health Board failed to respond to the complaint she submitted in July 2024. The Ombudsman found that the Health Board had not provided a final complaint response. She said this caused uncertainty and frustration for Mrs X. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to, within 6 weeks, issue the complaint response which will include an apology and explanation for the delays, and offer a £200 financial redress payment in recognition of the delays and for the time and trouble.