Report Date


Case Against

Swansea Bay University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Ms C complained about her father, Mr A’s care and treatment when he was taken to Morriston Hospital’s (“the Hospital”) emergency department (“the ED”) in September 2020. She was concerned that the correct stroke pathway had not been followed and a CT scan was not carried out. She was also dissatisfied that the Hospital had not responded to her concerns about her father’s deteriorating level of consciousness and his need for an urgent assessment. Finally, she was unhappy with the Health Board’s handling of her complaint.
The Ombudsman’s investigation concluded that it was not unreasonable to have diagnosed Mr A with a possible UTI on admission. While Ms C’s concerns about her father’s deteriorating consciousness the following day should have been escalated by the nurse for medical review at the time, and could have led to Mr A being reviewed sooner, the investigation concluded that the additional time delay had no impact on Mr A’s prognosis. These parts of Ms C’s complaint were not upheld. The investigation did find that a CT head scan should have been carried out on admission as there was evidence to suspect a stroke. This resulted in uncertainty for the family as to whether an earlier CT scan might have revealed an intra-cerebral bleed and therefore Mr A’s prognosis might have been different. The investigation also found shortcomings around complaint handling, and the robustness of the complaint response, had caused Ms C an injustice as she had to complain further in order to get answers. This had added to her distress. The Ombudsman therefore upheld these aspects of the complaint.
As well as apologising to Mr A and Ms C for the failings identified, the Health Board was asked to facilitate learning from Ms C’s complaint, which included discussing Mr A’s case in an anonymised form at an appropriate clinical forum.