Report Date


Case Against

Swansea Bay University Health Board


Clinical treatment in hospital

Case Reference Number



Early resolution

Mr A’s complaint centred on his late father’s management and care during his inpatient hospital admission including the management of the wounds that developed between his toes.
The Ombudsman in terms of pressure sore/wound management identified areas, especially around documentation, where shortcomings were evident and improvements could be made.
As part of the settlement of Mr A’s complaint the Health Board agreed to carry out a number of actions including apologising to Mr A and the family for the failings identified. It was also asked to ensure that wound assessment charts clearly identified each wound being managed and that any discussion/plan and rationale regarding tissue viability management were documented in patients’ records. Finally, the Health Board should ensure any discharge documentation referred to the management and plan of any identified wounds.