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 treatment and care received by her late uncle, Mr B, during his stay on Dan Danino Ward (the Ward) at Morriston Hospital (the First Hospital) between 6 March and 3 July 2019. In particular, she complained that Swansea Bay University Health Board (the Health Board) failed to adequately assess Mr B’s mental capacity to make decisions about his own care and safeguard him as a vulnerable adult during his stay on the Ward, to provide reasonable care and treatment to Mr B in respect of the cellulitis to his legs, and to communicate appropriately with Mr B’s family regarding their concerns about his treatment and wellbeing.

The Ombudsman found that Mr B’s mental capacity and safeguarding were given due consideration during his hospital stay, and an appropriate care plan was in place to treat Mr B’s cellulitis, but he was mostly non-compliant with his treatment which hampered his recovery. Therefore, these complaints were not upheld. However, opportunities were missed to engage the family in supporting Mr B with his treatment and a more proactive approach to communication could have been taken. The distress this failing caused was an injustice to Ms A and this aspect of the complaint was upheld.

The Ombudsman recommended that within 1 month of the report the Health Board should apologise to Ms A for the failings identified and make a redress payment of £250 in recognition of the time and trouble of bringing her complaint to the Ombudsman. He also recommended that the report be shared with the clinicians involved for critical reflection and learning regarding communication with patient’s families.