Report Date


Case Against

Swansea Bay University Health Board


Referral to treatment time

Case Reference Number



Upheld in whole or in part

Mr D complained that he had waited a long time for orthopaedic surgery and that his understanding of how he 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.
Mr D was removed from the waiting list when he missed surgical appointments because he was in hospital for another illness. Despite provision in the guidance for this type of situation, Mr D was removed from the list and is waiting to be “treated in turn” which appears to be outside of the process. 65 months (5 and a half years) after being added to the list for surgery, he is still waiting for treatment. He is in a lot of pain, and this has affected his wellbeing significantly.

Mr D was also put through the stress and pain of pre-operative assessments, which had raised his hopes that surgery would happen soon when the Health Board would have been aware that it was unable to provide surgery before the pre-operative assessment expired. It failed to take this into account or tell the patients.

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 issues identified she has asked the Health Board to review the decisions it made in respect of Mr D. 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.