Report Date


Case Against

Swansea Bay University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Mr A’s complaint on behalf of his late wife, Mrs A, related to delays in his wife’s breast cancer treatment in 2019 at the Singleton Hospital which his wife felt had contributed to her poor prognosis. The complaint also referred to the delay in responding to and treating a tumour that had spread to Ms A’s neck as well as poor communication when it came to Mrs A’s cancer care. The complaint set out the inadequacies in the Health Board’s complaint handling.

The Ombudsman’s investigation found that the delays in treatment had not affected Mrs A’s prognosis and outcome as her cancer was already advanced and prognosis poor at the time of her initial assessment. As the radiotherapy planning treatment scans were not to a diagnostic standard, the fact that retrospectively the tumour in Mrs A’s neck could be identified did not mean that her cancer care was inappropriate. The Ombudsman did not uphold these aspects of the complaint.

The Ombudsman identified communication failings and also felt that Mrs A should have been made aware of her poor prognosis earlier than in fact happened. The Ombudsman concluded that the additional stress, coupled with the lack of clarity and uncertainty on occasion around Mrs A’s management and care had caused Mrs A and the family an injustice. To this extent, the Ombudsman upheld this part of the complaint.

Additionally, the Ombudsman found administrative delays led to a delayed complaint response and although the response was broadly robust the Ombudsman considered that communication failings could have been addressed more. As the administrative failings around complaint handling had compounded Mrs A’s distress at a difficult and challenging time and caused an injustice, this part of the complaint was upheld.

The recommendations to the Health Board included apologising to Mr A for the failings and reviewing communication with patients particularly around poor cancer prognosis.