Report Date


Case Against

Swansea Bay University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Ms A complained about the care her son, B received when he was a patient on the Neonatal Ward at Singleton Hospital. The investigation considered whether B’s arterial cannula/peripheral arterial line(“the arterial line”) was inserted, maintained and monitored appropriately, and the arterial sampling procedure (the process of taking a blood sample) and the flushing procedure (the flushing of infusion fluid to prevent the arterial line clotting) were also undertaken to an appropriate clinical standard. In addition, whether the clinical cause of the acute ischemic injury (an injury caused by a decrease in blood flow) suffered could be definitively ascertained. Finally, whether there were factual inaccuracies in the Serious Incident Report (“SIR” – an investigation undertaken via the Health Board’s serious incident investigation process).

The investigation found that the arterial line was inserted maintained and monitored and the flushing procedure was undertaken to an appropriate clinical standard. It was not possible to definitively ascertain the cause of B’s acute ischemic injury however the 2 possibilities put forward by the Health Board were reasonable. There was one factual inaccuracy in the SIR. B was described as having been discharged with a fully recovered right upper limb however he had purple/blackspots over the nail bed of third and fourth fingers and Ms A described that 2years on, B still has no fingernails on the affected fingers, and as a family, they face uncertainty regarding his future. The Health Board had already apologised for the error and had revised the SIR. No further remedial action was recommended.