Report Date


Case Against

Swansea Bay University Health Board



Case Reference Number



Voluntary settlement

Mr A complained about whether the Health Board appropriately considered his mother’s case as part of its nosocomial review process (a process set up by Welsh Government for Health Boards to review cases where a patient may have contracted Covid-19 in hospital) and in line with the National Framework and any other relevant policies/procedures.

The investigation found that, although the review carried out by the Health Board into the care supplied to the complainant’s mother concluded it was reasonable, the explanation about how that decision had been reached was insufficiently detailed. The decision that there was no breach of duty and no qualifying liability was also not explained.

The Health Board had reached a decision to revise the content of decision letters to improve the way it communicated key issues, in light of issues raised by the Ombudsman. However, given the timing of the complaint, this improvement did not impact the complainant’s case.

The Ombudsman therefore reached an agreement with the Health Board for it to carry out afresh, thorough, nosocomial review, to include consideration of nosocomial, duty of care and qualifying liability issues. When that had been concluded, the Health Board agreed to write to the complainant to provide a fulsome explanation of the reasons for its decision within 6 weeks of the closure of the complaint.