Report Date


Case Against

Hywel Dda University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Mrs O complained that Hywel Dda University Health Board (“the Health Board”) failed to order and take timely blood tests for her mother, Mrs W, while she was in the community in November 2021. Mrs O also complained that the Health Board failed to manage Mrs W’s immunosuppressant medication (used to suppress rejection in organ transplant recipients appropriately.

The Ombudsman found that there were administrative issues that delayed the blood tests being taken. Despite this, the time between the blood test request and the blood sample being taken was clinically appropriate. The administrative issues had already been appropriately addressed by the Health Board. This complaint was not upheld.

The Ombudsman found that there was a failure to recognise the importance of obtaining regular and accurate levels of Mrs W’s immunosuppressant medication. Although monitoring subsequently improved, the initial failing meant that, for the first 3 weeks of her admission, Mrs W’s tacrolimus levels were probably higher than usual for her and exceeded her recommended safe dose. This may have slightly decreased her chance of survival, although it was not possible to say that her outcome could have been different. This uncertainty for the family about what difference that might have made to her final days was an injustice to them. This complaint was upheld.

The Health Board agreed to apologise to Mrs O and her family, and to offer her financial redress of £1000, in recognition of the impact of Mrs W’s uncontrolled tacrolimus levels, and the uncertainty around their significance in her ultimate outcome.

The Health Board also agreed to share the Ombudsman’s report with all staff involved in and consulted on Mrs W’s care during her admission, and also across the Health Board for wider learning and reflection. Finally, it confirmed that it would provide evidence to the Ombudsman of updated information and instructions for requesting tacrolimus blood tests and sending samples to the Laboratory for all staff, and that it would highlight where staff can find that information.