Mrs Z complained about the care and treatment that she had received from Swansea Bay University Health Board. The investigation considered whether there was a failure to assess Mrs Z’s injury properly when she attended hospital, which led to a failure to diagnose a hamstring tear, and if this led to Mrs Z not being referred for more timely management and treatment of her injury. The investigation also considered whether Mrs Z’s complaint to the Health Board was handled appropriately.
The investigation found that the assessment Mrs Z underwent when she attended hospital was appropriate and that a diagnosis was made in line with relevant guidelines. This aspect of Mrs Z’s complaint was not upheld. Mrs Z was not referred for timely management and treatment of her injury, but this was due to an insufficiently detailed discharge summary, not a failure to diagnose her injury appropriately. This part of Mrs Z’s complaint was partially upheld. Mrs Z received a response to her complaint in line with the relevant regulations. This part of Mrs Z’s complaint was not upheld.
The Ombudsman recommended that the Health Board apologise to Mrs Z for the failure to complete a sufficiently detailed discharge summary, and to offer her a payment of £125 in recognition of the delay this has caused in her receiving appropriate treatment for her injury. The Ombudsman also recommended that the Health Board remind the doctor that treated Mrs Z of the importance of completing sufficiently detailed discharge summaries.