We have today issued a Special Report after Swansea Bay University Health Board failed to implement key recommendations arising from a Public Interest Report following an investigation into the management of an orthopaedic patient’s waiting time for surgery.
In November 2025, we published a Public Interest Report after upholding a complaint from a complainant about a delay in receiving total knee replacement surgery from the Health Board, which he said he had been waiting for since August 2019. The investigation found that the complainant’s position on the waiting list had been mismanaged with no clinical review of whether the patient was medically fit to have surgery. In addition, the patient had not been informed of the Health Board’s decision to reset his position on the waiting list, in line with the Welsh Government’s Rules for Managing Referral to Treatment Waiting times.
The Health Board accepted the findings and recommendations in full. While it completed two recommendations, it failed to complete two further recommendations that were due by February 2026, which had been made to provide assurance on whether the Health Board’s waiting list is being appropriately managed and to ensure that staff receive appropriate training to apply the Welsh Government’s Rules correctly.
As we had previously issued 3 public reports in January 2024 finding similar issues in relation to the Health Board’s management of its orthopaedic waiting lists, we recommended that the Board should arrange an independent audit of its orthopaedic waiting list to establish if any other patients had been treated unfairly and that staff receive appropriate training.
The Health Board has failed to comply with the two outstanding recommendations. As a result, the Ombudsman has taken the unusual step of using her powers under the Public Services Ombudsman (Wales) Act 2019 to issue a Special Report.
Michelle Morris, Public Services Ombudsman for Wales, said:
“I remain deeply concerned that other patients may still be at risk of their waiting time not being managed in line with the relevant guidance.
“Given my previous investigations into the Health Board's orthopaedic waiting list, the audit that followed, and the lack of progress in implementing the outstanding recommendations from Mr W's case, independent scrutiny of the waiting list and appropriate staff training remain essential."
We have now made further recommendations requiring the Health Board:
- within 4 weeks, to provide an amended case study and evidence of its distribution, provide the scope and timetable for an independent audit, and present the report to its Board.
- within 12 weeks, to provide evidence that training has been developed to address the failings identified in Mr W’s case.
- within 16 weeks, to provide the independent audit findings, evidence that any patients affected by incorrect waiting time dates have received an apology and had their records corrected, and evidence that the updated training has been implemented.
We have also confirmed that the Special Report will be shared with the Chair of Swansea Bay University Health Board, the Cabinet Secretary for Health and Social Care, and Healthcare Inspectorate Wales.
We note that, in commenting on the draft of this report the Health Board has agreed to implement these recommendations.