Report Date

09/06/2025

Case Against

Swansea Bay University Health Board

Subject

Clinical treatment in hospital

Case Reference Number

202408837

Outcome

Early resolution

Mrs A complained about the standard of care provided to her late mother, Mrs B, when she was an inpatient at Morriston Hospital in 2022. She highlighted concerns about nursing care and a delayed diagnosis of Cushing’s syndrome. In its response to the complaint, the Health Board acknowledged that there had been a breach of duty of care in relation to the delayed referral and diagnosis of Cushing’s syndrome. However, the Ombudsman’s view was that it had not given adequate reasons for its conclusion that there was no qualifying liability (harm) in this case, and that the matter should be referred through the statutory redress process.

The Health Board therefore agreed to: Within 2 months

  • Refer Mrs A’s complaint back through the statutory redress process(under regulation 26) for assessment of level of harm due to the delayed referrals and diagnosis of Cushing’s syndrome.
  • Provide an additional written response to Mrs A about the learning andimprovement resulting from her complaint.