Public interest report: Cwm Taf Morgannwg University Health Board (202400797)

This report is issued under s.23 of the Public Services Ombudsman (Wales) Act 2019.

We have taken steps to protect the identity of the complainant and others, as far as possible.

Ms A complained about the Health Board’s delay in hip surgery for her father, Mr B. Mr B was told that his care had been transferred to a neighbouring health board. However, enquiries revealed he was not on the surgery waiting list at either health board. The investigation considered whether Mr B’s hip surgery had been delayed due to administrative, rather than clinical, reasons.

The Ombudsman found that, without his knowledge, Mr B had been removed from the orthopaedic surgery waiting list. The reason for this is not clear from the Health Board’s records. The Ombudsman was concerned that Mr B had not been notified about his removal from the list (as required by national guidance), and that the Health Board had failed to rectify the situation for well over a year despite complaints being made to it. The Ombudsman was satisfied that this constituted maladministration which had resulted in a considerably longer wait for surgery for Mr B. The Ombudsman upheld the complaint.

The Ombudsman made a number of recommendations which the Health Board accepted.

Within 1 month:

a) Arrange for the Chief Executive to make a written apology to Ms A and Mr B for the administrative error which delayed Mr B’s surgery, and for the poor and delayed response to their complaint.

b) Provide a redress payment of £750 to reflect the poor response to the complaint, and the additional stress for Mr B of having to chase up the issue with the Health Board.

c) Provide a redress payment of £1,500 to reflect the additional pain and suffering experienced by Mr B during the 18 months he was not on the waiting list due to administrative error.

Within 4 months:

d) Provide evidence to my office that it has audited its surgery waiting lists and the transferred patient lists to satisfy itself that there are no other surgery patients who have been similarly overlooked or wrongly removed from its lists.

e) Share this report with its Board which should nominate a Committee to maintain oversight and monitoring of the Health Board’s compliance with recommendation d).

1. Ms A complained about the delay in hip surgery for her father Mr B. Specifically, she stated that he had been waiting for several years for a hip replacement, but when enquiries were made, Mr B was told that he was no longer on the waiting list for surgery as his care had been transferred to another health board. However, further enquiries revealed he was not on the surgery list for that health board either. Ms A therefore complained to my office. My investigation considered whether Mr B’s hip surgery had been delayed due to administrative, rather than clinical, reasons.

2. My Investigation Officer obtained comments and copies of relevant documents from Cwm Taf Morgannwg University Health Board (“the Health Board”) and considered those in conjunction with the evidence provided by Ms A. It is noted that Mr B had a number of health conditions and received care for those throughout the period referred to in this report; the content of this report focusses solely on the timeline of his orthopaedic surgery and the administrative handling of this.

3. Both Ms A and the Health Board were given the opportunity to see and comment on a draft of this report before the final version was issued.

4. Welsh Government Rules for Managing Referral to Treatment Waiting Times (“RTT guidance”) Version 7, October 2017.¹

• Paragraph 96 states: “If a patient is removed from the waiting list for reasons other than treatment, the patient and their referrer must be informed of the removal and the reasons for it. The information given must include the full reasons for removal and guidelines specifying the requirements for a return to the A full audit trail of this communication must be maintained.”²

1 The RTT guidance was updated in April 2025. Planned care waiting times guidance: April 2025

2 The same provision is in the updated version of the RTT guidance (paragraph 139)

5. Mr B had been previously referred to the orthopaedic team with pain and restricted movement in both hips. At a consultation with a consultant orthopaedic surgeon (“the Orthopaedic Consultant”) on 16 November 2021, Mr B was placed on the waiting list for bilateral hip replacement surgery (the left hip to be replaced first on an urgent basis). It was noted that he had a number of other conditions, including high BMI, sleep apnoea, nephrotic syndrome (where protein leaks from the blood into the urine causing swelling) and diabetes.

6. He attended an orthopaedic pre-operative assessment clinic (“PAC”) on 21 January 2022 where he was seen by a consultant anaesthetist (“the Consultant Anaesthetist”). The Consultant Anaesthetist noted Mr B’s other health issues and recommended that surgery should take place at Princess of Wales Hospital.

7. Mr B was further reviewed by the Orthopaedic Consultant on 30 August. Dietary management to improve Mr B’s BMI was to be considered and the plan remained the same to continue with hip surgery.

8. A further PAC took place in April 2023. The records of this indicated that Mr B was “desperate for surgery”. On 26 May 2023, Mr B’s PAC results were reviewed by the Consultant Anaesthetist. Mr B’s condition was unchanged but his HbA1c (a measurement of average blood glucose levels over the past 2 to 3 months) was raised. A letter to Mr B’s GP from the Consultant Anaesthetist, dated 5 June, stated:

“Unfortunately, an HbA1c taken at Pre-Assessment was 80, suggesting that he is still diabetic. Ideally this needs to be improved before his hip replacement to reduce the risk of complications. I would be grateful if you could review this patient’s diabetic control and let me know when this has been improved.”

9. On 24 January 2024, Mr B’s GP contacted the Health Board to ask for confirmation about Mr B’s status on the waiting list for hip surgery. The GP explained that Mr B had contacted the Health Board directly to check the current waiting time but was told that he was no longer on the list. A response from the Health Board to the GP, dated 13 March, stated:

“I can see a letter to yourselves from [the Consultant Anaesthetist] (26/5/23) requesting that you review p[atien]t for better control of HbA1c, asking to let us know when achieved. Patient has an […]post[code] so now dealt with by [a neighbouring health board (“the Second Health Board”)]. I have spoken to the original listing consultant and he is now going to refer to a colleague in the Second Health Board. Can you confirm that his diabetes is now under control and he is fit for surgery.”

10. The GP’s response, dated 24 March, stated:

“I note your comments with regards to this gentlemen’s diabetes. Indeed looking historically at his HbA1c’s, they have never creeped above 65 so certainly not a poorly controlled type 2 diabetic by any means. To that end his HbA1c has improved to 55. As you can appreciate it is not for us in Primary Care to tell you whether or not he is fit for surgery and that will fall at the feet of the anaesthetist to make that decision. I hope you appreciate where we are coming from with regards to this.”

11. The Orthopaedic Consultant referred Mr B to another orthopaedic consultant (“the Second Orthopaedic Consultant”) at the Second Health Board in a letter dated 21 March. The letter explained that Mr B’s home address fell within the Second Health Board’s current geographic area. The letter explained that:

“when the restructuring happened, [Mr B’s] case should have been transferred to [the Second Health Board], but for some reason his case was lost. I have been asked recently to refer this gentleman to one of the hip surgeons in [the Second Health Board]. This gentleman has been waiting for hip replacement for a long time and when he enquired he was told that he is not on the waiting list, therefore, he has been quite angry, as we can understand and he has put in a complaint. Following his complaint, I have been asked to transfer his care to one of the hip surgeons in the Second Health Board and I would be grateful if you could take over his care and review his history”.

12. The Health Board provided a formal response to Mr B’s complaint about the delay in surgery. Its letter, dated 16 April, set out a chronology of treatment provided to Mr B, and explained that:

“In the summer of 2023 your GP was asked to assist you with your diabetic control. At this time [the] Health Board transferred all patients with an […] prefix postcode to [the Second Health Board]. You were not transferred at this time because you were not fit to proceed with surgery (until your Diabetes control had improved). I am pleased to confirm that [the Orthopaedic Consultant] has recently written a referral to [the Second Orthopaedic Consultant] to take over your care and to establish the best option for you to undergo hip replacement.”

13. There was further email correspondence in early May 2024 between the Health Board and the Second Health Board following a request from Ms A’s advocate for a copy of the referral letter. This prompted further communication between the Health Boards about the status of the referral. It was noted that the Health Board had “not received any confirmation yet” that the referral had been accepted by the Second Health Board. Further emails explained that the Second Health Board’s Planned Care Team had not accepted Mr B’s case onto its list. This was because “the patient was never transferred to [the Second Health Board] and […] has missed the cut off for transferring so either he is treated at [the Health Board] or he comes across to us as a new referral”. It was further noted that the Second Health Board had not been aware of the patient as he was not on the WPAS [Wales Patient Access Scheme – this is the administrative system used in Wales for patient details and hospital visits] and that matter “had been raised back in November” 2023 following the complaint.

14. The Second Health Board confirmed in an email of 10 May that they were “not accepting this referral as it has been sent after the repatriation cut-off date”.

15. It remained that Mr B was not on the waiting list at either the Health Board or the Second Health Board despite ongoing communication from Mr B, Ms A, Ms A’s advocate and my office. Mr B was eventually seen at the Health Board by another orthopaedic consultant to assess his suitability for surgery in January 2025. He was placed back on the urgent orthopaedic surgery waiting list in January 2025. His hip replacement surgery took place in May 2025.

16. Ms A initially emailed the Health Board on 2 June 2023 about Mr B’s lengthy wait for surgery and asked for his surgery to be expedited. This was acknowledged on 5 June. Mr B sent an email to the Health Board dated 19 October raising a concern about his ongoing wait for surgery. At the same time, Ms A sought support from an advocate to assist her in pursing the complaint to the Health Board. Additionally, Mr B said that he had phoned the Health Board about his surgery only to be told that he was not on the surgery waiting list. In December, Mr B’s local Member of the Senedd (“MS”) wrote to the Health Board, on Mr B’s behalf, to chase up a response about the delay in Mr B’s orthopaedic surgery.

17. Ms A made a complaint to my office in February 2024 as she remained concerned about Mr B’s wait for surgery and she had received no response to her complaint from the Health Board. In response to our enquiries, the Health Board informed my office that Mr B’s care had been transferred to the Second Health Board as Mr B was a patient in its area; it had therefore passed the complaint to the Second Health Board to respond to. The Health Board accepted that it should have informed Ms A about this and agreed to write to her to apologise. Ms A’s advocate emailed my office on 21 March stating that the Second Health Board had received no complaint concerning Mr B’s surgery delay and also that Mr B was not on its surgery waiting list. Following various emails to chase up a response, the Health Board issued its formal complaint response on 16 April. Following the Health Board’s formal response to the complaint (see paragraph 12 above), Ms A referred the matter back to my office as she was concerned that the Health Board had stated that Mr B had been referred to the Second Health Board and yet, on enquiry, it had confirmed to her that Mr B was not on its waiting list for surgery.

18. Ms A complained about the delay in her father, Mr B, getting surgery. She said that it was distressing to witness his ongoing wait for surgery when he was in considerable pain. The ongoing uncertainty about his situation on the waiting list, indeed about which Health Board was supposed to be treating him, had added to his stress. She referred to poor communication from the Health Board and the lack of clarity, and contradictions, in the Health Board’s response to her complaint. She also had to keep contacting the Health Board to chase up what was happening and getting no response.

19. The Health Board’s response to the complaint was set out in its formal response to Mr B dated 16 April 2024 (see paragraph 12 above). It confirmed that Mr B was placed on the urgent waiting list for hip replacement surgery on 16 November 2021. It stated that he should have been transferred over the Second Health Board in the Summer of 2023.

20. In later responses to my office, the Health Board confirmed that records indicated that Mr B was removed from the surgery waiting list on 7 July 2023. It is not clear from the records why he was removed. The Health Board referred to the letter to Mr B’s GP about his elevated HbA1c results as a potential reason for this.

21. The Health Board confirmed that Mr B was reinstated on the urgent list for hip surgery in January 2025.

22. Having seen a draft version of this report, the Health Board stated its view that the raised HbA1c result meant that Mr B was medically unfit for surgery in May 2023. It said that this is why Mr B was removed from the waiting list in July 2023. However, it acknowledged this was not communicated to Mr B or his GP, nor was it evident from its own clinical or waiting list records. It stated that it was unfortunate that this period coincided with the transfer of the orthopaedic patient list to the Second Health Board following restructuring, resulting in Mr B’s case being overlooked. However, the Health Board also accepted that it had missed opportunities to reinstate Mr B onto the waiting list, and that there was an unacceptable delay before it did so.

23. I am satisfied that there is evidence that administrative failings led to Mr B’s orthopaedic surgery being delayed and that throughout this time he continued to experience pain and restricted mobility. Mr B was accepted onto the Health Board’s waiting list for hip replacement surgery in November 2021 as an urgent patient. It is acknowledged that Mr B had various co-existing health conditions which made his situation more complex. However, he was removed from this list on 7 July 2023. The Health Board has suggested that this was following a high HbA1c result in May 2023, however the reason for Mr B’s removal from the waiting list is not evidenced in any of the Health Board’s records. Neither Mr B nor his GP were informed about his removal from the waiting list, contrary to the RTT guidance. An attempt to transfer Mr B’s care to the Second Health Board failed and no further action was taken to progress his care. He was never reinstated onto the waiting list despite considerable correspondence.

24. Mr B was eventually reviewed by the Health Board’s surgical team in January 2025 and reinstated on the urgent surgery waiting list. This represents a period of 18 months when he had been removed from the urgent waiting list, without being told, and was not reinstated even when the Health Board became aware that he should be on the waiting list. I am satisfied that his absence from the waiting list during this period related to administrative errors by the Health Board, rather than any clinical reason. I uphold the complaint.

25. The Health Board’s administration and communication throughout this complaint has been poor. Its responses to the complaint and to requests for information from my office have been delayed and incomplete. Whilst it may be understandable for an error to have occurred during the transfer arrangements of a number of patients to the Second Health Board, it is extremely concerning that the Health Board neither recognised nor rectified the error that had occurred. There were significant and numerous opportunities for the Health Board to have discovered the situation and corrected it, including approaches from June 2023 onwards from Ms A, Mr B, Mr B’s MS, Mr B’s GP and my office highlighting the situation.

26. In its responses, including the formal response to Mr B under Putting Things Right (“PTR”), the Health Board has given incomplete and misleading information. It repeatedly stated that Mr B had been referred to the Second Health Board when he had not been. Indeed, a referral letter was only sent in March 2024 less than a month before its formal response to Mr B under PTR. When that referral was refused by the Second Health Board in May 2024, the Health Board did nothing to remedy the situation, nor did it contact Mr B. The result of this has been that Mr B remained off the surgery waiting list from July 2023 until January 2025. It has also meant additional time and stress over a prolonged period for him and Ms A in chasing up the situation with the Health Board and dealing with its wholly inadequate responses.

27. Finally, the findings from my investigation of this complaint raise significant concerns about the way in which waiting lists are managed and how waiting times are represented and recorded by the Health Board. Mr B was removed from the urgent surgery list (after already waiting 19 months) without either him or his GP being informed. The reason he was removed is unclear. This is unacceptable and contrary to the RTT guidance.

28. Because Mr B was only reinstated on the surgical waiting list in January 2025, and his surgery took place in May 2025, the official figures will record his waiting time (referral to treatment time) as 5 months. In actual fact, he had been waiting for urgent surgery since November 2021, a total of 42 months. Even taking into account the short periods of time when Mr B was undergoing other treatment, and that his surgery was listed for a major hospital only, this is an excessive difference and calls into question the consistency of recording and therefore the accuracy of some of the Health Board’s waiting list data.

29. The numerous failings highlighted in this investigation, and the Health Board’s inability to explain or remedy Mr B’s situation even once it became aware of it, suggest that there may be other patients who have been similarly affected by removal from the waiting list without notification. It further raises significant concerns about the consistency of how waiting list data is recorded, and the need to be transparent with patients about any change in waiting list status. In light of this, I intend to share a copy of this report with the Cabinet Secretary for Health and Social Care.

30. I recommend that the Health Board should:

Within 1 month of the date of this report:

a) Arrange for the Chief Executive to make a written apology to Ms A and Mr B for the administrative error which delayed Mr B’s surgery, and for the poor and delayed response to their complaint.

b) Provide a redress payment of £750 to reflect the poor response to the complaint, and the additional stress for Mr B of having to chase up the issue with the Health Board.

c) Provide a redress payment of £1,500 to reflect the additional pain and suffering experienced by Mr B during the 18 months he was not on the waiting list due to administrative error.

Within 4 months of the date of this report:

d) Provide evidence to my office that it has audited its surgery waiting lists and the transferred patient lists to satisfy itself that there are no other surgery patients who have been similarly overlooked or wrongly removed from its lists.

e) Share this report with its Board which should nominate a Committee to maintain oversight and monitoring of the Health Board’s compliance with recommendation d).

31. I am pleased to note that, in commenting on the draft version of this report, the Health Board agreed to implement these recommendations.

32. In addition, the Health Board stated it was committed to learning from this case and ensuring that improvements were embedded within its services. It said that a current patient pathway audit was already ongoing. It explained it had already ensured that there was continuous validation of its waiting lists and started training all staff on the waiting list process, and the new guidance.

Michelle Morris 

Ombwdsmon Gwasanaethau Cyhoeddus | Public Services Ombudsman

20 November 2025