Report Date


Case Against

Hywel Dda University Health Board


Clinical treatment in hospital

Case Reference Number



Early resolution

Mrs S raised concerns with the Health Board about her husband’s care during his admission to hospital in January 2022. Mrs S had said that her husband had contracted COVID-19 in hospital and that he had been given extra blood-thinning medication that, she believed, caused internal bleeding. In correspondence from August 2022, the Health Board were asked to respond to these concerns and to provide “a detailed explanation as to the rapid deterioration” in her husband’s health during his admission.
The Health Board responded on 25 July 2023. It explained that it believed Mr S had contracted COVID-19 before his admission. It acknowledged that Mr S was given an extra dose of blood-thinning medication but said that it did not consider this would have caused any harm and that there was no evidence Mr S suffered any internal bleeding. It explained that Mr S deteriorated owing to his COVID-19 and associated kidney and lung failure. Mrs S wrote a statement of reply to the Health Board’s complaint response, which raised a number of new questions and was sent to the Health Board on 11 October 2023.
The Ombudsman found that there were delays in acknowledging the original complaint, and the complaint response was issued nearly 2 months beyond the 6 months allowed by the complaints handling process. Although the Health Board had apologised for the delays and had provided updates throughout the investigation, there was also evidence of poor document management including a repeat request for consent, despite it having already been received. In addition, the letter of 11 October, providing the further concerns that had arisen for Mrs S, was overlooked and had not received an acknowledgement or a response.
The Health Board agreed to apologise for the cumulative effect of these complaint handling shortcomings and to offer £100 in recognition of the fact that they had caused more time and trouble for Mrs S in pursuing her complaint than would normally be expected. It also agreed to provide a response, in line with the complaints handling process, to the further concerns raised on 11 October 2023.