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 Health Board’s management of her miscarriage (pregnancy loss) in January2020. Mrs A said that the Health Board failed to identify her miscarriage when she first presented with symptoms, to carryout an ultrasound scan to confirm that the miscarriage had fully completed, to advise her when to seek advice for complications, and to provide compassionate care when she was later admitted as an emergency with complications.

The Ombudsman could not say with certainty that Mrs A’s baby had died when she first presented with symptoms and consequently could not find that the Health Board had failed to identify her miscarriage. Further, an earlier ultrasound scan was not clinically indicated and would not necessarily have been definitive in identifying the complications she went on to experience. On Mrs A’s emergency admission, a side room for privacy with enhanced support from the Bereavement Midwife was arranged providing appropriate and supportive care. However, the Health Board’s record keeping around discussions with Mrs A about disposal of the pregnancy remains and the possible complications of miscarriage was found to be poor. The lack of evidence gave rise to an element of doubt about the choice Mrs A made for the disposal of the pregnancy remains, which she regretted, and the possibility that she delayed seeking urgent medical care because she was not appropriately advised. This caused Mrs A unnecessary pain and distress.

The Ombudsman recommended to the Health Board that it should apologise to Mrs A for the failings identified and pay her financial redress of £500 in recognition of the uncertainty and distress caused. It should also share the findings of the investigation with its midwives to ensure organisational learning.