Report Date


Case Against

Swansea Bay University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Mrs X complained about the care and treatment that her late daughter, Miss X, received from Swansea Bay University Health Board (“the Health Board”) during her admissions to Morriston Hospital in early 2019. Specifically, she complained about the Health Board’s delay in confirming her daughter’s diagnosis, which resulted in a delay in treatment and palliative care. She also raised concerns about the Health Board’s management of her daughter’s pain levels.

The Ombudsman concluded that, rather than being a matter of when exactly Miss X’s diagnosis was received, there had instead been a more general delay in recognising the speed with which her cancer was progressing and her deterioration. As such, he concluded that Miss X’s rate of deterioration and the clear problems with controlling her pain should have meant that palliative care and symptom relief was considered a priority sooner, which might have improved the management of her situation. This lost opportunity amounted to an injustice to both Miss X and her family. The Ombudsman also found that, whilst a combination of factors in Miss X’s case meant that it probably would always have been very difficult to effectively control her pain, earlier and more active input from the Pain Team and senior palliative care clinicians might have resulted in better pain management. As a result of the above, the Ombudsman upheld both complaints.

The Ombudsman recommended that the Health Board apologise to Mrs X and share his report with the relevant clinicians for them to reflect on its findings. He also recommended that the Palliative Care Team and the Acute Pain Team review and reflect on the management of Miss X’s case and, in doing so, consider how any scope for improvements that are identified can be implemented in practice. The Health Board agreed to implement the recommendations.