Report Date


Case Against

Swansea Bay University Health Board


Clinical treatment in hospital

Case Reference Number



Early resolution

Mrs X complained about the lack of communication from the Health Board regarding the care provided to her husband and his prognosis. She said that this meant that she was unable to spend her husband’s last moments with him.
The Ombudsman found that there were failings in the Health Board’s communication with Mrs X. She sought the Health Board’s agreement to improve its communication with relatives, particularly in relation to end of life care. The Health Board agreed to take a number of actions to remind staff about the importance of inviting relatives into the Emergency Department.
This included the use of posters as prompts for staff to speak to family if the patient had a DNAR (do not attempt cardiopulmonary rescusitation) decision in place or had been commenced on the end of life pathway.
The Health Board agreed to provide evidence that it had carried out these actions within 20 working days.