We publish today two public interest reports concerning significant failings by Swansea Bay University Health Board and Cwm Taf Morgannwg University Health Board in managing orthopaedic surgery waiting lists. In both cases, patients were removed from waiting lists inappropriately and without being informed, contrary to Welsh Government’s Rules for Managing Referral to Treatment Waiting Times.
The first report finds that Swansea Bay University Health Board inappropriately re-set Mr W’s waiting time clock for knee surgery without informing him. As a result, he has now lost the opportunity to undergo surgery.
The second report finds that, due to administrative errors, Cwm Taf Morgannwg University Health Board removed Mr B from its hip surgery waiting lists without his knowledge, after he had already been waiting 19 months. The reason for this removal is not clear from the Health Board’s records.
Michelle Morris, the Ombudsman, said:
“These cases show the very real human impact of poor administration. Patients were removed from, or had their waiting times reset on, orthopaedic surgery lists without being informed, contrary to national guidance, causing unnecessary pain, anxiety and uncertainty.
In the Swansea Bay case, Mr W contacted my office after seeing media coverage of three Public Interest reports we issued earlier this year on the Health Board’s management of orthopaedic waiting lists, in which the Health Board had committed that no patient would wait more than three years by the end of March 2024. At that point, he had already been waiting five years and four months.
Those earlier reports recommended a full audit of the waiting list to identify any further errors, including inappropriate resetting of waiting times or removal from the list. It is deeply concerning that further errors have now been found despite that audit, raising serious questions about its reliability.”
The First Report – Swansea Bay University Health Board – 202407678
Our report issued today finds patient lost opportunity for knee surgery after waiting time clock was wrongly re-set in October 2023.
The complaint
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 his waiting time was managed appropriately under the Welsh Government’s Rules for Managing Referral to Treatment Waiting Times, specifically when his waiting time clock was re-set in October 2023.
What we found
We found that Mr W’s waiting time clock was inappropriately re-set in October 2023. There was no evidence that a clinician had documented he was medically unfit to proceed with surgery. A repeat scan, required due to the time he had waited, confirmed his fitness for surgery.
The decision to re-set the waiting time clock was not communicated to Mr W; he only became aware when he made a complaint. As a result, he experienced pain, reduced mobility, and ongoing frustration. He is now unable to proceed with surgery, representing a serious and ongoing injustice.
In January 2024, our office published three public interest reports into the Health Board’s orthopaedic waiting list management. Each case found patients had been treated unfairly due to administrative errors. One of the recommendations contained within those reports was that the Health Board audit 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 mistakes occurred despite this audit, raising questions about its reliability.
Commenting on the report, Public Services Ombudsman for Wales, Michelle Morris, said:
“Mr W had seen in the media that this office had previously investigated cases where patients were treated unfairly by the Health Board, and that the Health Board had promised no patient would wait more than three years by March 2024. It must have been a huge shock for him to learn his waiting time was recorded as just over 60 weeks, when he had believed he had been waiting more than five years.
The Health Board has provided no evidence that a clinician deemed him medically unfit in October 2023. The multiple errors in managing his case are deeply concerning and point to wider systemic failings in the Health Board’s management of waiting lists and application of RTT guidance.”
Our recommendations
We made a number of recommendations, all of which the Health Board accepted. These included:
- apologising to Mr W and sharing the report with staff.
- appointing an independent person to re-audit the orthopaedic waiting list, to identify and correct any further errors, and agree the audit scope with the Ombudsman before it begins.
- providing staff training to ensure RTT guidance is correctly applied in similar cases.
- sharing the report with its Board, which should appoint a Committee to oversee compliance with these recommendations.
The Second Report – Cwm Taf Morgannwg University Health Board – 202400797
Our report issued today finds administrative errors caused a patient to be removed from the orthopaedic surgery waiting list after already waiting 19 months.
The complaint
Ms A complained about Cwm Taf Morgannwg University 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 that he was not on the surgery waiting list at either health board.
What we found
Our investigation considered whether Mr B’s hip surgery had been delayed due to administrative, rather than clinical, reasons. It found that, without his knowledge, Mr B had been removed from the orthopaedic surgery waiting list after already waiting 19 months. The reason for this is not clear from the Health Board’s records.
We were 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 over a year, despite complaints being made. We concluded that this constituted maladministration, resulting in a considerably longer wait for surgery.
Commenting on the report, Public Services Ombudsman for Wales, Michelle Morris, said:
“Mr B was removed from the waiting list due to administrative errors by the Health Board, not for any documented clinical reason. During this time he experienced considerable pain, and the uncertainty over which Health Board was responsible for his care added further stress for him and distress for his daughter, who watched him wait without clarity or resolution.
This case highlights serious concerns about how waiting lists are managed and how waiting times are recorded and communicated by the Health Board. The inconsistency in recording data and lack of transparency with patients is unacceptable and undermines trust in the system.
The numerous failings highlighted in this investigation, and the Health Board’s inability to address or explain the situation even after becoming aware of it, suggest that other patients may have been similarly affected. Whilst it may be understandable for an error to have occurred during the transfer of patients to the second Health Board, it is deeply concerning that the Health Board neither recognised nor corrected the mistake.”
Our recommendations
We made a number of recommendations, all of which the Health Board accepted. These included:
- Apologising to Ms A and Mr B.
- Providing financial redress to Mr B to reflect the stress caused and the additional pain he suffered.
- Providing evidence that it has audited its surgery waiting lists and the transferred patient lists to ensure no other surgery patients were similarly overlooked or wrongly removed.
- Sharing the report with its Board, which should appoint a Committee to oversee compliance with recommendation 3.