Report Date


Case Against

Swansea Bay University Health Board


Adult Mental Health

Case Reference Number



Early resolution

Mrs A complained to the Health Board about the delay on the part of its Mental Health Service in getting her mother the correct urgent medical attention and required nursing care, whilst she was resident in a care home. In her complaint submission to the Ombudsman, Mrs A said that she disagreed that the Health Board had followed The National Health Services (Concerns, Complaints and Redress Arrangements) (Wales) Regulations 2011 (“the Regulations”) in its investigation of her complaint.

The Ombudsman found that the complaint response from the Health Board did not comply with the Regulations. It failed to specifically address Mrs A’s complaint about delays on the part of the Health Board in getting her mother medical/nursing care, and it appeared to be a chronology of events only. Further, it did not comment on whether the Health Board considered that there were missed opportunities to intervene in her mother’s care, or if the deterioration in her mother’s physical condition were noted at the time of the visits from the Health Board staff. Additionally, it made no comment on whether there was any qualifying liability on the part of the Health Board, which the Regulations stipulate that the response should include.

The Ombudsman sought and gained the Health Board’s agreement to provide Mrs A with a response to her complaint, in accordance with the Regulations, within 20 working days.