Report Date


Case Against

Swansea Bay University Health Board



Case Reference Number



Upheld in whole or in part

Mr B complained about the midwifery care his partner, Ms C, received from Swansea Bay University Health Board (“the Health Board”). In particular, Mr B complained that the proposed referral of Ms C to JIG-SO (a service initiated by the Health Board and the Local Authority to provide midwifery support) was not appropriate.

The Ombudsman’s investigation found that Ms C received appropriate midwifery care and treatment. In accordance with relevant guidance, Ms C had frequent and regular appointments with a midwife and arrangements were made for Mr B to be present for all appointments, at a time when such arrangements were restricted owing to the COVID-19 pandemic. The investigation also found that the midwife’s referral to JIG-SO was appropriate. However, there was no documented discussion with Ms C about JIG-SO and what services it offered, and the JIG-SO information leaflet was not up to date. Ms C should have been involved in discussions about her care in order to be able to make an informed decision about whether she wanted to be referred. The investigation found that the midwife did not enable Ms C to make an informed choice, which was out of step with national guidance. This caused distress to Ms C which was an injustice. Accordingly, Mr B’s complaint was upheld to this extent.

The Ombudsman recommended that the Health Board apologise to Ms C and make a redress payment of £250 for the failing identified. He also recommended that the Health Board share the report with relevant clinical staff for critical reflection and learning, review and update its JIG-SO information leaflet and service specification, and remind midwives in the Health Board’s midwifery service of the importance of involving pregnant women in discussions about their care, to enable them to make informed decisions.