Source · PSOW (Public Services Ombudsman for Wales)

Swansea Bay University Health Board

PSOW (Public Services Ombudsman for Wales) Upheld Reference PSOW-202402035 Sector Health Category Other Decided 04 September 2025

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Full decision

a) There was an unnecessary delay in Swansea Bay University Health Board (“the Health Board”) arranging Mr A’s surgery from January 2022 onwards.

b) The Health Board provided Mr A with regular and appropriate updates.

The investigation found that there was an unnecessary delay, especially in 2023, in the Health Board arranging Mr A’s surgery. Even taking into account the extended accounting/ordering and purchasing process, as the chosen manufacturer was a new supplier, Mr A potentially could have had his operation almost a year earlier, and possibly even earlier than this. Mr A’s surgery eventually took place in February 2025.

The Ombudsman concluded that the failings that led to the unnecessary delays in Mr A’s operation amounted to maladministration and caused service failings. The delayed procedure also resulted in Mr A suffering an injustice. Mr A referred to the impact on him which included a deterioration in his mental health. This part of Mr A’s complaint was upheld.

The Ombudsman identified communication shortcomings on the part of the relevant Department’s Manager. As a result, this adversely affected the appropriateness and regularity of the updates that the treating consultant and his secretary provided to Mr A. In the absence of communication to the contrary, their expectation was that the order was being progressed by the Manager and the evidence shows that this was not always the case. The Ombudsman concluded that the communications failings were again maladministrative and contributed to service failings which caused Mr A an injustice. This is because it added to Mr A’s frustration and his deteriorating mental health which he referred to. This aspect of Mr A’s complaint was also upheld.

The Health Board accepted the Ombudsman’s recommendations which included making a written apology to Mr A and a financial redress payment of £750. The latter was in recognition of the distress and frustration caused to Mr A due to the unnecessary delays which had led to the arrangement for Mr A’s operation taking longer than it might have. The Health Board also agreed to review its process for facilitating orders in the relevant departmental team to satisfy itself that there were sufficient monitoring processes in place to ensure timely arrangements/completion of orders.

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Reference Date Summary Outcome
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