Report Date


Case Against

Swansea Bay University Health Board


Clinical treatment outside hospital

Case Reference Number



Upheld in whole or in part

Mrs G complained that Swansea Bay University Health Board failed to provide appropriate care and treatment for her mother’s cancer.

The Ombudsman’s investigation found that while the clinical approach to diagnosing the cancer affecting Mrs G’s mother, Mrs O, was within the range of appropriate practice, there was an avoidable delay by the relevant Multidisciplinary Team (“the MDT”) in carrying out necessary investigations. This delayed the point at which surgery was attempted, following which Mrs O was informed that the cancer was not curable. While earlier treatment would, sadly, not have altered the course of Mrs O’s cancer, the delay prolonged the uncertainty for her and her family at a time when they were understandably anxious for clear information. The investigation also found that there was a 4-6 week delay in providing Mrs O with a chemotherapy appointment after the surgery. This further delay would have caused additional distress and anxiety for Mrs O and her family. Accordingly, the Ombudsman upheld the complaint.

The Ombudsman recommended that the Health Board make a fulsome apology to Mrs G and her family for the delay in diagnosing and treating Mrs O’s cancer. She also recommended that the Health Board should ensure that the findings of the report are considered by a relevant clinical governance forum to agree specific actions to ensure that:

• the MDT arranges investigations and procedures in a timely manner

• where clinical findings suggest that a palliative oncology referral is appropriate, an immediate referral is made without waiting for MDT approval.