Report Date


Case Against

Swansea Bay University Health Board


Referral to treatment time

Case Reference Number



Upheld in whole or in part

Mrs B said that she had waited a long time for orthopaedic surgery and that her understanding of how she would be treated was not managed well regarding the pre-operative assessments.

The waiting time for orthopaedic surgery at the Health Board is more than 4 years. The Health Board had issues including not enough staff, not enough suitable places to operate, unclear management arrangements, and unclear processes for these operations.

The Ombudsman identified that in this and 2 other cases, in addition to the long delays experienced by all patients awaiting orthopaedic surgery, the complainants had been treated unfairly because of errors in the way the waiting lists were managed. These issues raised the Ombudsman’s concerns about how the waiting list has been managed.
Mrs B was referred in 2018 for right hip pain and again in 2021 for left hip pain. The referral for her left hip was closed in error, but in 2023 her left hip was treated (instead of her right hip as it was clinically worse) and she was removed from the waiting list for her right hip, even though this still required treatment. She continues to experience severe pain in her right hip 5 years after initial referral and is still waiting for it to be operated on.

Mrs B was also put through the stress and pain of a pre-operative assessment, which raised her hopes that surgery would happen soon. This was due to an administrative error.

The Ombudsman noted that the Health Board has taken action to address the length of its waiting lists so made no recommendations about that. However, because of the waiting time issues identified, she has asked the Health Board to review the decisions it made in respect of Mrs B and her position on the waiting list. The Health Board was also asked to audit the whole of its waiting list to establish whether errors had been made on the waiting list times or improper removal from the list for other patients and if so, it should apologise to those patients and correct the errors.