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Clinical treatment in hospital: Swansea Bay University Health Board

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Clinical treatment in hospital


Upheld in whole or in part

Case ref number


Report type

Non-public interest report issued: complaint upheld

Relevant body

Swansea Bay University Health Board

Ms K complained about the treatment her late mother, Mrs L, received from Swansea Bay University Health Board (“the First Health Board”) and Hywel Dda University Health Board (“the Second Health Board”). In particular, she said that:
The First Health Board
• Failed to diagnose and treat Mrs L’s cancer in a timely manner and that the failure to operate sooner resulted in her premature death.
• Failed to provide Mrs L and her family with an adequate level of information regarding her test results and treatment options.
The Second Health Board
• Failed to keep Mrs L informed as to the extent of her cancer and its clinical progression and provided conflicting information regarding surgery and treatment options.
• Failed to provide Mrs L with appropriate medication and nutrition prior to her death.

The Ombudsman’s investigation found the following:
The First Health Board
• Although the Welsh Government’s Suspected Cancer Pathway timeframe was missed, the First Health Board failed to take proactive action when a procedure could not take place due to a lack of anaesthetists. This delay meant there was a significant impact for Mrs L in that there was poor local tumour control which was the predominant cause of her cancer related symptoms.
• There was a delay in Mrs L being given information about liver metastases as there were opportunities missed to communicate this information at an earlier stage.
Both of these parts of the complaint were upheld.
The Second Health Board
• Although Mrs L received appropriate treatment and interventions, communication was poor with her family, national guidelines were not followed and there was confusion as to why certain decisions were made. In addition, a drug error was not reported to the family until after Mrs L’s death. This part of the complaint was upheld.
• Mrs L was provided with appropriate medication and nutrition prior to her death. This part of the complaint was not upheld.
The Ombudsman recommended that both health boards apologise to
Ms K and review how they communicated with Mrs L and feed back any improvements to the Ombudsman and Ms K.