Report Date


Case Against

Swansea Bay University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

The investigation found that Mrs A was not fully aware of how unwell her husband was, and the paramedics and clinicians ought to have known this and further consideration should have been given to involving Mrs A in her husband’s care. Mrs A was not informed about the do not attempt cardiopulmonary resuscitation (“DNACPR” this informs clinicians that a patient does not wish to be resuscitated if their breathing or heart stops), which was discussed with Mr B in the early hours of the morning. Mrs A should have been informed of the DNACPR decision as soon as it was practically possible. These issues, combined with the overall failure to communicate with Mrs A about how unwell Mr B was, meant that the Health Board missed the opportunity to update Mrs A about her husband’s condition and treatment.

The Ombudsman recognised that this was challenging for the Health Board in the context of the COVID-19 restrictions, however it also meant that Mrs A’s opportunity to be with her husband was further limited. Given this more thought and urgency should have been given to communicating an updated position with her sooner than in fact occurred. The Health Board had previously offered its unreserved apology for this missed opportunity, and for the impact this had had on Mrs A. The Ombudsman upheld Mrs A’s complaint, to the extent that the overall communication shortcomings meant that she was not able to be involved in her husband’s care or be present at the end of his life to reassure and support him, and this was an enduring injustice to Mrs A.

The Ombudsman recommended that WAST and the Health Board apologise to Mrs A for the failings identified in the investigation. WAST, as part of wider learning, was asked to carry out a clinical review of Mr B’s case and discuss clinical features and management with the attending crew including the appropriateness of time at the scene and documenting. The Health Board was asked, if it had not already done so, to remind the medical and nursing team of the expected level and method of communication and frequency of updates that should be given to patients’ families.