Report Date


Case Against

Swansea Bay University Health Board


Clinical treatment in hospital

Case Reference Number



Early resolution

Mrs X complained about care and treatment provided to her son during his admission to hospital from December 2021 to March 2022. Specifically, her complaint related to the fact that prior to his admission to hospital, her son’s skin was intact. However, during his admission he developed suspected pressure sores, and, upon discharge, he was unable to walk unaided, and community nursing was required to attend to dress and treat the sores for a period of 3 months.

The Ombudsman found that the Health Board’s complaint response to Mrs X had not adequately addressed her concerns about how/why her son had developed the sores. The Health Board had failed to make enquiries with its relevant departments to try to identify the cause of the sores, and in doing so, failed to identify whether Mrs X’s son required any ongoing treatment. She also found that the Health Board had not included reference to the safeguarding investigation, or its outcome, instigated when Mrs X’s son was admitted to Morriston Hospital in March 2022. Finally, the Ombudsman was concerned that there was an apparent failure to arrange community nursing care for Mrs X’s son, prior to his discharge.

The Ombudsman contacted the Health Board and in resolution of Mrs X’s complaint it agreed to, within 20 working days, provide a further written response to her, which addressed the outstanding issues as detailed.