Report Date


Case Against

Swansea Bay University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Mrs A complained about the care and management she had received since November 2018 under the Colorectal Team at Morriston Hospital (“the Hospital”). This included the failure to fit a colostomy bag during surgery in early November 2018, which meant that she developed life threatening/changing complications and later required emergency surgery to fit the colostomy bag. She was concerned about the lack of a treatment plan to address the problem, and repeated appointments. She was also unhappy with Health Board’s handling of her complaint.
We found that Mrs A’s inpatient medical and nursing care on 1 November and her subsequent inpatient admissions were broadly reasonable and appropriate, and this aspect of her complaint was not upheld.

The Ombudsman’s investigation found significant shortcomings, including protracted delays in Mrs A’s management and care with no clear treatment plan being put in place to address her ongoing complications. There was also a lack of coordinated clinical decision-making and rationale by the clinicians involved in Mrs A’s care which was not in keeping with accepted clinical practice. These clinical shortcomings were compounded by the lack of access to operating theatres and cancellation of outpatient appointments. The Ombudsman concluded that a timelier intervention might have alleviated some of Mrs A’s symptoms and reduced the impact on her mental health and wellbeing sooner than occurred. It may also have lessened the wider effects on her family and the relationship she had with them.

Whilst the Ombudsman is not able to make definitive findings of a breach of the Human Rights Act, she can comment on the Health Board’s regard for these rights. The Ombudsman was satisfied that both Mrs A and her family’s Article 8 rights were engaged as the failure to address Mrs A’s ongoing issues with her fistula meant that her dignity was compromised. Given the embarrassment caused to Mrs A by the daily leakage from her back passage, she did not feel comfortable going out. Mrs A also felt a burden on her family due to the caring responsibilities they had to undertake. The Ombudsman found that this loss of dignity, and the undermining of Mrs A’s feelings of self-worth caused a significant injustice to her and her family. This aspect of her complaint was upheld.

In terms of complaint handling, given the complexity of Mrs A’s case, the Ombudsman found that the delay in providing a response was not unreasonable. However, the shortcomings around the timeliness of Mrs A’s subsequent care were not identified by the Health Board in its complaint response to Mrs A. Therefore, opportunities to learn lessons were missed. This aspect of Mrs A’s complaint was upheld to that limited extent only.

The Ombudsman recommended that the Health Board apologise to Mrs A for the shortcomings identified and that it pays a sum of £1000 for the failings identified in the management of her care. Recommendations to assist clinicians in reflective and wider learning were also made. The Health Board was also asked to share the Ombudsman’s report with its Patient Safety and Clinical Governance Group.