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Clinical treatment in hospital : Swansea Bay University Health Board

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Clinical treatment in hospital


Upheld in whole or in part

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Non-public interest report issued: complaint upheld

Relevant body

Swansea Bay University Health Board

Mrs A complained about the care and treatment provided to her mother, Mrs B, by the Health Board. Specifically, she complained that:

a) The Health Board failed to appropriately investigate and treat the cause of Mrs B’s knee pain following her arrival at Morriston Hospital (“the First Hospital”) on 27 January 2021
b) The transfer of Mrs B to Neath Port Talbot Hospital (“the Second Hospital”) on 1 March 2021 was unsafe.

The Ombudsman’s investigation found that the Health Board had failed to carry out appropriate investigations in response to Mrs B’s ongoing, unexplained knee pain and decline in mobility. This was a service failure. As a result, the diagnosis of Mrs B’s dislocated knee was delayed by several weeks and Mrs B lost the opportunity to receive earlier treatment which could potentially have significantly improved her mobility and relieved her pain. This was a serious injustice. Accordingly, the Ombudsman upheld complaint a) The investigation also found that, whilst the transfer to the Second Hospital was not clinically unsafe, Mrs B should not have been transferred before appropriate investigations of her knee had been carried out. Therefore, complaint b) was upheld to the limited extent that Mrs B was deprived of care which could potentially have avoided the need for a transfer.

The Ombudsman recommended that the Health Board should apologise and make a payment of £1,000 to Mrs A in respect of the injustices arising from its failings. She also recommended that the Health Board should remind relevant clinical staff of the importance of documenting multidisciplinary discussions and of carefully reviewing radiology reports, and that it should produce an action plan to address other significant failings. The Health Board agreed to implement the recommendations.