Report Date


Case Against

A GP Practice in the area of Swansea Bay University Health Board


Clinical treatment outside hospital

Case Reference Number



Upheld in whole or in part

Mr X’s complaint related to the care and treatment that his late son, Mr Y, received from a GP Practice in the area of Swansea Bay University Health Board following his diagnosis of chronic pancreatitis in February 2017. Specifically, Mr X complained about the GP Practice’s management of his son’s condition, which included concerns surrounding the adequacy and monitoring of pain relief, the lack of action taken on receipt of 3 photographs and a “Do Not Resuscitate” letter on separate occasions, and whether appropriate referrals to hospital to investigate, by way of scans, the severity of his pain had been made. Mr X also raised concerns about 2consultations in particular that occurred a few days before Mr Y’s death. Lastly, Mr X complained that the GP Practice had discriminated against his son on the basis of him being a recovering alcoholic.

The Ombudsman concluded that the GP Practice took reasonable and appropriate actions to try to manage Mr Y’s pain levels, and that his pain relief medication was appropriately monitored with reasonable explanations about its usage having been given to him. The Ombudsman also found no evidence to indicate that the GP Practice had failed to make appropriate referrals for the purpose of investigating the severity of Mr Y’s pain, particularly as he was already under the care of appropriate specialists in secondary care. Following on from this, the Ombudsman also concluded that the GP Practice had acted appropriately on receipt of Mr Y’s letter indicating that he did not want to be resuscitated. Although the Senior Partner had stated that he could not recall being shown the photographs of Mr Y by his mother, and that these photographs were not referenced within Mr Y’s medical records, the Ombudsman noted that there had nevertheless been no concerns with the management of Mr Y’s pain at any point during the period under review. As a result, the Ombudsman did not uphold these complaints. Given that there was no evidence that the GP Practice treated Mr Y inappropriately in terms of the care and treatment that it provided to him for his chronic pancreatitis, the Ombudsman also did not uphold Mr X’s complaint that the GP Practice had discriminated against his son. However, the Ombudsman concluded that the consultations with Mr Y on 20 and 21 June 2019 respectively were not carried out to a reasonable standard or adequately documented. This caused an injustice to Mr X, as he had been left with the uncertainty about whether more could have been done for his son on these 2 occasions, and so the Ombudsman upheld these complaints.

The Ombudsman recommended that the GP Practice apologise to Mr X for the failings that she identified with the 2 consultations within a month of the date of the final report. She also recommended, within 3months of the final report, that the GP Practice carries out a review of the process for when prescriptions are signed by a different professional to the one who assessed the patient. The Ombudsman also invited the GP Practice to consider some additional improvement actions in relation to issues identified during the investigation but which were not part of the matters formally investigated.