Report Date


Case Against

Swansea Bay University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Mr W complained that, during 2 admissions to Singleton Hospital in January and February 2020, staff failed to carry out appropriate investigations to diagnose his wife’s brain tumour.

The Ombudsman noted that, on her first hospital admission, Mrs W had been referred by her GP because she was tired, had pain in the head and had felt off balance and had been dropping things. Whilst medical staff diagnosed hypercalcaemia (raised blood calcium) which was thought to be caused by Vitamin D supplements, the Ombudsman found that Mrs W had symptoms that could not be attributed to hypercalcaemia and that a brain scan should have been carried out. The Ombudsman found that when Mrs W was readmitted to hospital with worsening symptoms 10 days after discharge, a CT scan (the use of X-rays and a computer to create an image of the inside of the body) was appropriately done. However, the result of the scan were ambiguous, and the Ombudsman considered that it should have triggered a further scan. This was not done, and Mrs W was discharged from hospital for further specialist review. The Ombudsman found hat, as a result, Mrs W’s brain tumour was not diagnosed until she was readmitted to hospital 13 days later.

The Ombudsman found it very likely that if brain scans had been carried out during Mrs W’s first hospital admission, her brain tumour would have been diagnosed an earlier stage. Sadly, however, earlier diagnosis would not have affected the outcome as Mrs W’s brain tumour was aggressive and not amenable to treatment. Nonetheless, the Ombudsman found that the delay in diagnosis led to worry and distress both to Mrs W and her husband, which was a significant injustice to them. The Ombudsman upheld the complaint.

The Ombudsman recommended that the Health Board apologise to Mr W for its failings. She also recommended that it share her report with medical staff to highlight the failings identified and ensure that lessons are learnt, and to provide evidence that it had done so.