About the complaint

The Ombudsman launched 3 separate investigations after receiving complaints about the management of orthopaedic waiting lists at Swansea Bay University Health Board.

All 3 complainants said that they had waited a long time for orthopaedic surgery and that their understanding of how they would be treated was not managed well by the Health Board regarding pre‑operative assessments.


What the Ombudsman found

The Ombudsman found that currently, the waiting time for orthopaedic surgery at the Health Board is more than 4 years.

The Health Board has had issues including not enough staff, not enough suitable places to operate, unclear management arrangements, and unclear processes for these operations.

The Ombudsman’s investigation found the following failings relating to management of the waiting list:

1. Mrs B was referred to hospital in 2018 for right hip pain and again in 2021 for left hip pain. The referral for her left hip was closed in error, but in 2023 her left hip was treated (as it was clinically worse).  She was removed from the waiting list for her right hip, even though this still required treatment.  Mrs B continues to experience severe pain in her right hip and after 5 years is still waiting for it to be operated on.

2. Mr C had been assessed as needing surgery within a month but waited 43 months (3 years 7 months) whilst in severe pain. During that time his position on the waiting list was reset in error and he was also removed from the list in error.

3. Mr D was removed from the waiting list when he missed surgical appointments because he was in hospital undergoing treatment for another illness. Despite provision in the guidance for this type of situation, Mr D was removed from the list and was waiting to be “treated in turn” which appears to be outside of the process.  Mr D received treatment in January 2024, 65 months (more than 5 years) after being added to the list for surgery. Mr D experienced a lot of pain, and this affected his wellbeing significantly.

These failings raised the Ombudsman’s concerns about how the whole waiting list has been managed.

The complainants were also put through the stress and pain of pre-operative assessments. These had falsely raised their hopes that surgery would happen soon.

“While patients are waiting for surgery on the list, they should be treated fairly in relation to the management of their place on that list, how they are communicated with about the time it is likely to take to receive treatment and to have their expectations fairly managed.

Patients who are already facing lengthy waiting times should feel able to rely on the Health Board to manage the waiting list well and in accordance with the waiting list guidelines.

These 3 cases demonstrate clear injustice to the patients.  In addition to these failings, the complainants had the unnecessary stress and pain of pre-operative assessments.  I am concerned that there appears to have been no thought for the impact of these on the patients’ wellbeing."

Commenting on the report, Public Services Ombudsman for Wales, Michelle Morris, said:


The Ombudsman made the following recommendations:

  • the Health Board to review the decisions it made in respect of these complainants and their positions on the waiting list
  • the Health Board to audit the whole waiting list to establish whether errors had been made on the waiting list times or improper removal from the list for other patients; and if so
  • the Health Board should apologise to those patients and correct the errors.

Swansea Bay University Health Board has accepted the Ombudsman’s findings and conclusions and has agreed to implement these recommendations.


Click here to read the 3 reports.