Public interest report: Swansea Bay University Health Board (202407678)

This report is issued under s.23 of the Public Services Ombudsman (Wales) Act 2019.

We have taken steps to protect the identity of the complainant and others, as far as possible. The names of the complainant and others have been changed as well.

Mr W complained about a delay in receiving a total knee replacement surgery from Swansea Bay University Health Board, which he had been waiting for since August 2019. The investigation considered whether Mr W’s waiting time for surgery was appropriately managed in line with the Welsh Government’s Rules for Managing Referral to Treatment Waiting Times, specifically when his waiting time clock was re-set in October 2023.

The investigation found that Mr W’s waiting time clock was inappropriately re-set in October 2023. It found no evidence that a clinician had documented that Mr W was medically unfit to proceed with surgery. Mr W required a repeat scan, due to the amount of time he had been waiting, which confirmed his fitness to proceed. The decision to re-set the waiting time clock was also not communicated to Mr W and he only became aware when he made a complaint. As a result of the delay, Mr W had experienced pain, reduced mobility and ongoing frustration. Further to this, he is now in a position where he is not able to proceed with surgery and this opportunity has been lost.

In January 2024, this office published 3 reports in the public interest in relation to the Health Board’s management of the waiting list for orthopaedic treatment. These reports found that in all 3 cases the complainants had been treated unfairly because of errors in the way the waiting lists for orthopaedic surgery were managed. One of the recommendations contained within those reports was that the Health Board should carry out an audit of its waiting list to establish whether any other errors had been made relating to the resetting of waiting list times or improper removal from the list. It is concerning that further errors have subsequently been found despite this audit having taken place. This raises concern about the reliability of the audit the Health Board undertook previously.

The Health Board agreed to the following recommendations:

a) Arrange for the Chief Executive to make an apology to Mr W for the failings identified in the management of his waiting time for surgery.

b) Share this report with relevant staff and reflect on the failings identified, in particular the need for there to be a well documented clinical decision before a patient is deemed unfit for surgery.

c) Appoint an independent person to re-audit its orthopaedic waiting list to establish if any other patients have been treated incorrectly in the same way as Mr W, including incorrect waiting time re-set date and/or not being informed of their waiting time clock being re-set. If any are identified, the Health Board should apologise to those patients and ensure the correct waiting list date is recorded. The Health Board should propose a scope for the audit that should be agreed by this office before the audit commences.

d) Given that the Health Board remained of the view, during the course of my investigation, that it was appropriate to reset the clock in Mr W’s case, it should ensure its training for staff on the application of the RTT guidance includes this type of scenario, to ensure that its approach to waiting list management is in keeping with the RTT guidance.

e) Share the report with its Board which should nominate a Committee to maintain oversight and monitoring of the Health Board’s compliance with these recommendations.

1. Mr W complained about a delay in receiving total knee replacement surgery from Swansea Bay University Health Board (“the Health Board”). The investigation considered whether Mr W’s waiting time for surgery was appropriately managed in line with the Welsh Government’s Rules for Managing Referral to Treatment Waiting Times, specifically when his waiting time clock was re-set in October 2023.

2. My Investigation Officer obtained comments and copies of relevant documents from the Health Board and considered these in conjunction with the evidence provided by Mr W. I have not included every detail investigated in this report, but I am satisfied that nothing of significance has been overlooked.

3. Both Mr W and the Health Board were given the opportunity to see and comment on a draft of this report before the final version was issued.

4. Welsh Government’s Rules for Managing Referral to Treatment Waiting Times (“RTT guidance”) Version 7, October 2017:

• In March 2005 the First Minister and Minister for Health and Social Services announced that, by December 2009, no patient in Wales will wait more than 26 weeks from GP referral to treatment including waiting times for any diagnostic tests or therapies required. The achievement of the 26 week RTT target is the responsibility of health boards.
• A maximum 26 week wait would be allowed for clinically complex patients, and different targets apply to certain types of treatment, such as diagnostic test (for example X-rays) and treatment for cancer. The wait time begins on receipt of a referral by a healthcare professional to a consultant and is the start of the waiting time clock. The clock can start or stop at certain designated points explained within the RTT guidance.
• Paragraph 76 includes “….Within a RTT period, the clock continues to tick until a clinical decision to stop is reached…”
• Paragraph 78 states “All referrals within an RTT period to diagnostic services, therapy assessments or anaesthetic assessment, will continue the clock.”
• Paragraph 88 states “When a patient is transferred between consultants for reasons of clinical necessity that prevents the current pathway being completed, the clock will stop. When this is simply a request for advice, this must be managed within the 26 week RTT period. The date on which it is explained to the patient that clinical responsibility for their care is being transferred to another consultant will be the clock stop date.”
• Paragraph 95 states “If, in the opinion of a suitably qualified healthcare professional, a patient has a medical condition which will not be resolved within 21 days, the patient should be returned to the referring clinician, or to another clinician who will treat the condition, and the clock will stop.”

5. The Health Board’s Patient Access Policy (2017). This states that patients may be removed from the waiting list when unfit to proceed for more than 3 weeks. Patients will be reinstated to the waiting list on notification that they are now fit. A new pathway will start and patients should be booked in taking into consideration their previous wait.

6. On 13 August 2019 Mr W was added to the Health Board’s waiting list for a left total knee replacement. Mr W was determined to be a category 3 patient (the Health Board uses 4 types of category – 4 is routine, 3 is urgent, 2 is very urgent and 1 is cancer or emergency care).

7. On 14 September 2020 Mr W underwent a pre-operative assessment and was declared fit for surgery.

8. Mr W was listed for surgery on 17 September in Neath Port Talbot Hospital. However, this surgery could not go ahead as it was identified that Mr W required his surgery in Morriston Hospital (“the Hospital”), due to his other underlying health conditions.

9. During the COVID-19 pandemic orthopaedic surgery was suspended at the Hospital. This caused a significant backlog of patients and increased waiting times, including for Mr W.

10. In November 2022 orthopaedic surgery at the Hospital recommenced.

11. On 2 October 2023 Mr W underwent tests with a nurse to inform a pre-operative assessment. On 6 October Mr W met with an orthopaedic surgeon who confirmed he was happy to proceed with surgery to Mr W’s knee. On 14 October the pre-operative assessment results were reviewed by a consultant anaesthetist (“the Anaesthetist”). The Anaesthetist requested an echocardiogram (“ECHO” – a scan used to create images of the heart and surrounding blood vessels). They also wrote to a consultant cardiothoracic surgeon to request a computerised tomography scan (“CT scan – the use of X-rays and a computer to create an image of the inside of the body) of Mr W’s heart, as it had been over 2 years since this was last performed. The pre-operative assessment form did not state anywhere on it that Mr W had specifically been assessed as unfit to proceed with surgery.

12. On 14 October Mr W’s waiting time clock was re-set. The reason given for this was that he was unfit to proceed with surgery at that Mr W was not informed of this decision.

13. On 3 November Mr W underwent an ECHO. A consultant cardiothoracic surgeon also wrote to the Anaesthetist and advised that a CT scan had been completed in November 2022 and therefore a repeat was not required.

14. On 2 February 2024 Mr W’s ECHO results were reviewed by the Anaesthetist and the pre-operative assessment form was updated. He was deemed medically fit to proceed with surgery.

15. On 25 November Mr W complained to the Health Board about his wait for surgery.

16. On 29 November Mr W underwent a further pre-operative assessment. A “frank” discussion about Mr W’s risks of surgery took place. Mr W was noted as wishing to proceed with surgery.

17. During November Mr W was upgraded to category 2 (very urgent).

18. On 12 December the Health Board issued a response to Mr W’s complaint in which it explained that his waiting time clock had been re-set in October 2023. It explained that Mr W was only suitable for surgery at the Hospital which was going through a period of sustained pressure. Mr W wrote back and stated that he had not previously been aware that his waiting time clock had been re-set.

19. On 17 December the Health Board wrote to Mr W again. It explained that as he required further investigations to ensure his fitness for surgery, he had been considered medically unfit for over 21 days, in line with the RTT guidance. It apologised that he had not been notified of this. It said Mr W’s pathway was correct and at that point, he had waited just over 60 weeks.

20. On 3 January 2025 Mr W complained to my office about his ongoing wait for surgery.

21. On 21 March Mr W attended a review with a consultant orthopaedic surgeon. It was decided that Mr W now lacked sufficient rehabilitation potential to undertake the intensive physiotherapy required to achieve a good pain-free result from the surgery. He was removed from the waiting list and a plan was made for pain management.

22. Mr W complained that he had been waiting over 5 years for surgery on his left knee. He said that it was only when he received a response from his complaint to the Health Board, in December 2024, that he found out that his waiting time clock had been re-set. He believed the Health Board was “cooking the books”.

23. Mr W had seen in the media the investigations carried out by this office which had identified patients being treated unfairly by the Health Board and that the Health Board reported that by the end of March 2024 no patient would have waited more than 3 years. However, he had been waiting 5 years and 4 months. He said the Health Board was now saying he had only been waiting 60 weeks, when in fact it was 276 weeks.

24. Mr W questioned how the Health Board could say he had been medically unfit for surgery for more than 21 days as he had not had any tests or consultations, other than pre-op assessments, following which he was told he was fine.

25. The Health Board said that it was appropriate to stop Mr W’s clock in October 2023 as he was deemed unfit to proceed with surgery and required intervention and investigations from cardiac services before being confirmed fit to proceed. It said this was in line with paragraph 88 of the RTT guidance. It said it had previously apologised that this information was not appropriately communicated to Mr W.

26. The Health Board said that it was unable to provide a copy of the correspondence sent to the Anaesthetist from a consultant cardiothoracic surgeon confirming that the CT scan had been completed in November 2022, as this could not be located. The Health Board also said that there was no documentation to support the change in Mr W’s category, from 3 to 2, as this may have been done during a phone call.

27. The Health Board stated that, due to administrative error, Mr W’s new clock was restarted the same day (14 October 2023). However, the new clock should have started from when he was deemed medically fit for surgery in February 2024. It said, therefore, Mr W had been advantaged by 4 months on the waiting list, as a result of this error.

28. The Health Board said that, in February 2025, while Mr W was awaiting further cardiac investigations following a pre-operative assessment, Mr W’s waiting list remained open. The Health Board said that he should have been removed from the waiting list, in line with RTT guidance. However, it said discretion had been used following discussions with the Health Board’s Chief Operating Officer, based on the length of time Mr W had already waited. Unfortunately, following a subsequent review, it had been decided that Mr W was no longer medically fit to proceed with surgery, and he had been removed from the list.

29. The Health Board said that it endeavoured to ensure all patients are kept informed of pathway changes but, due to staff turnover, it had been unable to identify if any staff members were asked to inform Mr W of his pathway change. It said that there was learning to be had, and it would ensure this was reinforced to the administrative teams. It said that staff were documenting, in the notes section of patient referrals, the date of contact with patients to ensure this was captured.

30. The Health Board said that in October 2023 the waiting time for surgery was 3-4 years and the target of no patient waiting more than 3 years for treatment by March 2024 was achieved. Therefore, it said that, had Mr W’s waiting time clock not been reset in October 2023, he would have received his surgery by March 2024.

31. In commenting on the draft investigation report, the Health Board said that relevant senior members of staff had reviewed Mr W’s waiting list pathway. It said that it had applied the RTT guidance correctly in removing Mr W from the waiting list as only patients considered ready for treatment should be actively waiting. When a patient could not be signed off by the pre-operative assessment as ready for treatment, as was the case for Mr W, and their care passed to another consultant then the original pathway is stopped and a new pathway begins. In providing its comments, the Health Board said it had applied paragraph 95 of the RTT guidance which states:

“If, in the opinion of a suitably qualified healthcare professional, a patient has a medical condition which will not be resolved within 21 days, the patient should be returned to the referring clinician, or to another clinician who will treat the condition, and the clock will stop. The clock stop date will be the date the patient is determined to be medically unavailable for this period.”

32. The Health Board said that it fully appreciated that improved and transparent communication with Mr W would have improved his patient experience, which was always of the utmost importance to the Health Board.

33. The Health Board subsequently further commented that, once it was known that Mr W did not require a repeat CT scan, the clock stop on his pathway should have been removed. The Health Board then confirmed that it accepted the draft report fully and its recommendations.

34. In January 2024, I issued 3 public interest reports (202200425, 202201496 and 202200361) in relation to the Health Board’s management of waiting lists for orthopaedic treatment. These reports detailed reasons for long waiting times for orthopaedic surgery at the Health Board. This included a lack of facilities, insufficient staff numbers, unclear management arrangements and unclear processes for these operations. The reports also detailed the action the Health Board was taking to address the waiting times. I have therefore not repeated this information here.

35. These investigations identified that in all 3 cases the complainants had been treated unfairly because of errors in the way the waiting lists for orthopaedic surgery were managed. As a result of these findings the Health Board agreed to audit the whole of its waiting list to establish whether errors had been made with the waiting list times, or if there had been any improper removals. The Health Board confirmed to my office that it had completed the audit of waiting times from April 2023. This found that patients had either been correctly managed in line with the RTT guidance or, where it identified errors, it stated they had not had a detrimental impact on the waiting time for any patient and in fact had put them ahead.

36. In commenting on the draft report, the Health Board provided further detail of the actions it had taken since these previous investigation reports were issued. It said that it had introduced safeguards to safety net patients who are removed from the waiting list and require optimisation, to ensure that they are not disadvantaged when they re-commence their wait when they are medically fit to proceed with their surgery. This included coding the patients with a specific code when they are removed from the waiting list so that they are visible to waiting list staff, tracked and regularly reviewed. Patients who are returned to the list have a specific priority to ensure they are visible and treated in line with their original waiting list date. The Health Board said it recognised its communication with patients required improvement and it had introduced a project group to address this. It said all calls to the Waiting List Department are now recorded so that there is a record of what was discussed. It also said that monthly waiting list audits are undertaken and reviewed to monitor patient pathways and appropriate application of the RTT guidance. Finally, the Health Board said it had introduced a “Planned Care Academy” to provide regular training and review of the RTT guidance and it had been chosen to host an all-Wales task and finish group for all health boards in Wales to work collaboratively to improve waiting lists. It will also be developing a system to address how the outcome of pre-operative assessments are communicated.

37. Mr W was added to the waiting list for orthopaedic surgery in August 2019. Without his knowledge, his waiting time clock was re-set in October 2023. The Health Board has already acknowledged that Mr W should have been informed of this decision and apologised for this. It must have been a huge shock for Mr W to read in the complaint response that his waiting time was recorded as being just over 60 weeks when he considered he had been waiting over 5 years.

38. During the pre-operative assessment in October 2023, it was decided that Mr W required further assessments to determine if he was fit to proceed with surgery. Mr W had previously been deemed fit for surgery but, as pre-operative assessments are only valid for 6 months, due to the length of time Mr W had needed to wait, further assessment was required.

39. The Health Board has said that it was appropriate to re-set Mr W’s clock at this time as he was unfit to proceed with the procedure. However, the Health Board has not provided any evidence of a clinician documenting that Mr W was medically unfit to proceed at this point.

40. The Anaesthetist’s pre-operative assessment in October 2023 noted that the last ECHO and CT scan were more than 2 years ago. The assessment then noted that an ECHO was requested, and a consultant was contacted about a repeat CT scan. It did not state that Mr W was medically unfit for surgery. The same document was subsequently updated in February 2024. The decision noted on the document was “Fit To Proceed”.

41. I do not accept the Health Board’s position that Mr W was clinically assessed as medically unfit to proceed with surgery. Instead, it was assessed that further information was required to determine his fitness to proceed. It was then found that a repeat CT was not necessary, and an ECHO was done 3 weeks later, although the results were not reviewed for a further 3 months. On the date that the information was assessed, he was found to be fit to proceed.

42. It is deeply concerning that, following my previous investigations into the Health Board’s management of orthopaedic waiting lists, it carried out a full audit but did not identify this error. In addition, the Health Board reviewed Mr W’s case when providing its complaint response and when providing comments to my office and yet it still did not recognise this error. The Health Board maintained its position that it was appropriate for a patient, who had already been waiting 4 years for surgery, to have his waiting time clock re-set. This was despite pre-operative assessments and tests needing to be repeated as a result of the Health Board’s backlog of patients. These assessments and tests subsequently confirmed Mr W’s fitness. This raises further concerns about whether other patients have also had their waiting time clock inappropriately re-set and calls into question the reliability of the audit undertaken as a result of the recommendations contained in my previous report.

43. The re-setting of Mr W’s waiting time clock in October 2023 was incorrect and amounts to maladministration. This resulted in Mr W not receiving his surgery, during which time he experienced pain, reduced mobility and ongoing frustration on a daily basis. Further to this, he is now in a position where he is not able to proceed with the surgery and this opportunity has been lost. This was, and continues to be, a significant and ongoing injustice to him. Mr W has expressed a wish for the Health Board to improve the service it provides, “to take the best care of the health of the people that they are responsible for.” Mr W is not seeking financial redress.

44. In addition, the Health Board itself identified errors in the management of this case. An administrative error occurred when re-setting the clock, although it considered this benefited Mr W by 4 months on the waiting list. It also acknowledged it should have informed Mr W of the change in his waiting time. It is very concerning that multiple errors have occurred in the management of Mr W’s case. The RTT guidance is clear that patients should be involved in decisions and these decisions be communicated to them. In fact, paragraph 88 of the RTT guidance, which the Health Board stated it applied in this case, is clear that the date the clock is stopped is the date that it is explained to the patient. Therefore, even if a stop at this point had been appropriate, it should not have been applied until this was explained to Mr W, which in this case did not happen. The failings identified in this case have led me to conclude that there are systemic failures in the Health Board’s management of its waiting lists and its understanding of the RTT guidance.

45. For the reasons outlined above, I uphold this complaint.

46. In view of the significant and systemic failings identified in this report, I am sharing my report with the Cabinet Secretary for Health and Social Care and Healthcare Inspectorate for Wales.

47. I was also concerned that, during this investigation, the Health Board was unable to provide copies of some evidence that was requested. In January 2022, my predecessor issued “Good Records Management Matters”. This detailed the importance of good record keeping, to create confidence in decision making, accountability and to enable others to verify what has been done. I invite the Health Board to consider this guidance and the importance of accurate record keeping.

48. I recommend that, within 4 weeks of the final report being issued, the Health Board should:

a) Arrange for the Chief Executive to make an apology to Mr W for the failings identified in the management of his waiting time for surgery.

b) Share this report with relevant staff and reflect on the failings identified, in particular the need for there to be a well documented clinical decision before a patient is deemed unfit for surgery.

49. I recommend that, within 12 weeks of the final report being issued, the Health Board should:

c) Appoint an independent person¹ to re-audit its orthopaedic waiting list to establish if any other patients have been treated incorrectly in the same way as Mr W, including incorrect waiting time re-set date and/or not being informed of their waiting time clock being re-set. If any are identified, the Health Board should apologise to those patients and ensure the correct waiting list date is recorded. The Health Board should propose a scope for the audit that should be agreed by this office before the audit commences.

d) Given that the Health Board remained of the view during the course of my investigation, that it was appropriate to reset the clock in Mr W’s case, it should ensure its training for staff on the application of the RTT guidance includes this type of scenario, to ensure that its approach to waiting list management is in keeping with the RTT guidance.

e) Share the report with its Board which should nominate a Committee to maintain oversight and monitoring of the Health Board’s compliance with these recommendations.

50. I am pleased to note that in commenting on the draft of this report the Health Board has agreed to implement these recommendations.

¹ A suitably qualified individual not employed by the Health Board

Michelle Morris

Ombwdsmon Gwasanaethau Cyhoeddus | Public Services Ombudsman

20 November 2025