Report Date


Case Against

Hywel Dda University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Mrs A complained that the Health Board failed to provide an adequate level of monitoring and treatment of her blood glucose levels while she was an inpatient at Bronglais General Hospital on 16 May 2020, and that it failed to appropriately manage her discharge from the Hospital on 17 May.
The Ombudsman found that Mrs A’s diabetic care had been appropriate and nursing staff had allowed Mrs A to have appropriate control over her own treatment. This aspect of the complaint was not upheld. The Ombudsman found that the Health Board did however fail to manage Mrs A’s discharge appropriately regarding pain management, and more should have been done to engage with specialist pain services before she left hospital. This approach could have helped Mrs A to better manage her pain as well as reducing the distress she experienced while awaiting surgery and not doing so constituted a failure of service on the part of the Health Board. This element of the complaint was upheld.
The Ombudsman recommended that, within 1 month, the Health Board should provide Mrs A with a written apology for the failings identified in this report and share the report with the clinicians involved in Mr A’s care for critical reflection and learning. He recommended that, within 6months, the Health Board undertake a review of the mechanisms in place, to ensure that patients admitted to an emergency hospital setting have timely access to specialist pain reviews where necessary prior to discharge. The Health Board should provide the Ombudsman with its findings and any subsequent action plan or procedural changes.