Report Date


Case Against

Hywel Dda University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Mrs T complained about the care and treatment she received while undergoing a termination of her pregnancy in 2021. She specifically complained that she was not given the option of having her termination as an inpatient on 13 September and was advised to contact the Sexual Health Service. She complained that when she attended the Emergency Department on 26 September there was an inappropriate delay in her receiving treatment and she had to travel to Glangwili Hospital (“the Hospital”) by car as there were no ambulances available despite being too unwell to do so. She also complained that, on 29 September, it was incorrectly assessed that her termination was complete and there was a delay, until 7 October, before she had a scan to confirm the termination had failed.
The investigation found that it was reasonable that Mrs T was advised to contact the Sexual Health Service to discuss her termination options. This aspect of the complaint was not upheld. The investigation also found that there was a delay in Mrs T receiving pain relief when she attended the Emergency Department. She also should have had her observations taken prior to her transferring independently to the Hospital, to ensure it was safe for her to do so, and she should have been given the option of waiting for an ambulance to transfer her. This aspect of the complaint was upheld. Finally, the investigation found that Mrs T was appropriately assessed and treated when she was admitted to the Hospital between 26 and 29 September. However, she should have been managed locally at the Hospital when she reported ongoing symptoms. This aspect of the complaint was upheld to this extent.
The Health Board agreed to implement the Ombudsman’s recommendations and apologise to Mrs T for the failings identified and make a redress payment of £500 for the discomfort and distress caused by these failings. It agreed to share the report with relevant staff and remind staff in the Emergency Department of the importance of pain assessment and timely administration of pain relief. It also agreed to consider the development of local guidelines for independent inter-hospital transfer and to review the appropriateness of pathways for patients undergoing termination of pregnancy and early pregnancy problems.