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Clinical treatment in hospital: Swansea Bay University Health Board

Report date



Clinical treatment in hospital


Non-public interest report issued: complaint upheld

Case ref number


Report type

Upheld in whole or in part

Relevant body

Swansea Bay University Health Board

Mrs A complained that her late father-in-law’s, Mr B, multiple discharges from the Assessment Units of both Singleton and Morriston Hospitals between 14 August and 31 August 2020 were not appropriate. She also complained that as part of discharge planning, communication with both the family and the residential Care Home was inadequate.

The investigation found that the level of care that Mr B received in relation to his blood sodium level (salt levels in the blood) at each of his 3 admissions fell below the standard expected. The reasons for this included insufficient monitoring and investigation of Mr B’s low sodium levels. In addition, looking at each discharge in isolation, more could have been done to address the deterioration in Mr B’s walking ability. The investigation also identified that communication could have been better and more effective than it was, including around documentation and the discharge process. The investigation found that the clinical failings identified amounted to service failings and the administrative failings around documentation was maladministrative. Whilst Mr B’s final outcome might not necessarily have changed, Mrs A and the family would have to live with the fact that aspects of Mr B’s care were not reasonable or appropriate, as well as the ensuing distress that his multiple discharges had caused them. This was the injustice to Mrs A and the family. Mrs A’s complaints were upheld.

The recommendations made included the Health Board apologising in writing to Mrs A for the failings identified, especially around Mr B’s low sodium levels during his 3 admissions. The Health Board was also asked to remind staff about the need to complete the discharge checklist.