Report Date


Case Against

Swansea Bay University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Ms A complained about the appropriateness of the care, management and treatment of her symptoms associated with Postural Orthostatic Tachycardia Syndrome (“PoTS”) by the Cardiology Department.

The investigation was unable to ascertain the reason for the delay in the availability of her test results (26 months), what speciality or clinician had access to and interpreted the results and consequently who formulated a firm diagnosis, or when this occurred. The investigation found that the medication suggested and prescribed by the Consultant Cardiologist was clinically appropriate, however the correspondence he sent to the GP was not. The investigation found appropriate action was not taken by the Consultant Cardiologist to either build on his own knowledge of PoTS or identify someone with a higher level of expertise. Consequently aspects of Ms A’s complaint regarding the communication of diagnosis, management of her condition and a lack of referral for a specialist opinion were upheld. The investigation found that it was clinically appropriate for Ms A to have been discharged from Cardiology in the summer of 2019.

Swansea Bay University Health Board (“the Health Board”) agreed to apologise to Ms A and ensure that the Consultant Cardiologist reflected and discussed the contents of his correspondence with the GP at his next appraisal. The Health Board agreed to research PoTS resources, assess whether it considered that Ms A would benefit from a referral to a clinician with a specialism in PoTS and undertake an investigation to ascertain whether the test results were received at any point prior to October 2020.