Report Date


Case Against

Swansea Bay University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Mrs L complained that staff in Morriston Hospital’s Intensive Therapy Unit (ITU) failed to administer appropriate sedation and oxygen to her daughter, Ms J, to ensure she was comfortable and free from distress in the final hours of her life.

The Ombudsman noted that Ms J, who had previously undergone a double lung transplant at an English Hospital, attended Morriston Hospital’s Emergency Department with deteriorating symptoms and increasing shortness of breath. Ms J was transferred to the Intensive Therapy Unit (ITU) for high flow nasal oxygen treatment (the delivery of higher flow levels of oxygen than can be achieved using a simple face mask). The Ombudsman noted that, following advice from the English Hospital that her condition was not amenable to treatment, Ms J was placed on an End-of-Life pathway with medication to treat anxiety, agitation and pain being prescribed. The Ombudsman also noted that an End-of-Life Care Plan was completed which stated that monitoring of vital signs and oxygen therapy were to be stopped and ventilatory support withdrawn.

The Ombudsman found that the End-of-Life medication prescribed and administered to Ms J for symptom control was appropriate. However, prior to starting on the End-of-Life pathway, Ms J had been heavily dependent on oxygen and struggling to breathe. The Ombudsman considered it could have been predicted that Ms J might experience breathlessness when the high flow nasal oxygen was removed, and that if a clear plan had been put in place to address the potential need to reinstate oxygen therapy, a distressing episode, when Ms J became severely agitated and distressed, might have been avoided. The Ombudsman found that the Health Board failed to manage the withdrawal of Ms J’s oxygen appropriately, causing suffering and distress to Ms J as well as distress to her family who witnessed these upsetting events. The Ombudsman also found that it would have been good practice for an ITU doctor to review Ms J, although she acknowledged that due to competing demands, this might not have been possible in practice. The Ombudsman upheld the complaint. The Ombudsman was pleased to note that the Health Board had updated its End-of-Life guidance as a result of learning from the complaint.

The Ombudsman recommended that the Health Board apologise to Mrs L for its failings. She also recommended that it pay Mrs L £1,000 redress in recognition of the suffering and distress to Ms J and the distress caused to her family.