Report Date


Case Against

Swansea Bay University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

In 2019 Ms A had a laparoscopic sleeve gastrectomy (a surgical weight loss procedure) at Singleton Hospital. Ms A subsequently complained of dizziness, food becoming stuck in the oesophagus and reflux. Ms A complained that during a telephone consultation on 16 November 2021 the food that she could not eat was not considered, and that she was not referred for a manometry test (to measure the pressure in the gullet and the valve separating the stomach and oesophagus). Ms A also complained that since 4 January 2022 she had no contact with the Bariatric Services.

The Ombudsman found before the 16 November 2021 consultation, a list of food that Ms A was intolerant of had been forwarded by a dietitian and nurse to the Consultant and these would have been considered. She also found that whilst delayed, Ms A was referred for a manometry test. While the referral was delayed it had not led to an injustice for Ms A. The Ombudsman found that there was no clinical record/letter of this consultation and on that basis only, this aspect of the complaint was upheld.

The Ombudsman also found that the contact Ms A received until 4 January 2022 was appropriate. She found that post bariatric surgical guidance advocates regular patient follow-up for up to 2 years, and that Ms A was followed up for nearly 3 years. This aspect of the complaint was not upheld.
The Health Board agreed to implement the Ombudsman’s recommendations within 1 month: apologise to Ms A for the failing and to highlight to relevant staff the importance of maintaining clinical letters/records for all consultations.