Report Date


Case Against

Swansea Bay University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Mrs A complained about the care and treatment that her late husband (Mr A) received from Swansea Bay University Health Board (“the Health Board.

The investigation found that capacity issues meant that Mr A faced a delay of 9 months between his initial and follow up appointment at the Gastroenterology Outpatient Clinic. If he had been seen earlier, the investigations undertaken may have identified cancer sooner. This uncertainty represented an injustice and accordingly this aspect of Mr A’s complaint was upheld.

The investigation also found that:

• There was evidence that Vitamin E and Pioglitazone treatments were mentioned to Mr A and the decision not to prescribe them was clinically appropriate

• Due to an administrative error, Mr A’s prescription for pain relief was sent to the wrong GP Practice. Whilst the discharge summary indicated that he was discharged with pain relief the Health Board had been unable to ascertain what the prescription was. Mr A had been advised to return to the hospital if his pain was severe and so it was open for him to do in the intervening period whilst the administrative error was being rectified.

• Mr A did not clinically require antibiotic therapy post discharge.

• The investigations undertaken around Mr A’s jaundice were appropriate and timely.

• There was no delay by the Gastroenterologist in making a referral to Oncology, a referral was made on the same day that the biopsy confirmed a cancer diagnosis.

• There was no evidence that Oncology had agreed to visit Mr A in hospital or that is was part of his clinical plan.

• There was no clinical evidence that Mr A had symptoms of biliary sepsis during admission in December 2019 and based on the documentary evidence Mr and Mrs A were informed on 23 March that Mr A was suffering from sepsis.

The Health Board agreed to apologise to Mrs A for the failings outlined within the report, and undertake a review of the impact that the remedial action is has already taken (the employment of 2 additional consultants) in an attempt bring down waiting list times has had on service provision.