Source · PSOW (Public Services Ombudsman for Wales)

Swansea Bay University Health Board

PSOW (Public Services Ombudsman for Wales) Partly Upheld Reference PSOW-202503905 Sector Health Category Clinical treatment in hospital Decided 22 July 2026

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Full decision

Ms H complained that her symptoms of stroke were not recognised and treated promptly and appropriately when she attended the Emergency Department (“the ED”) in March 2024. She also said that she was not appropriately monitored and she did not receive appropriate support to meet her toileting needs.

We found that there was no delay in staff recognising Ms H’s symptoms as a potential stroke, and appropriate action was taken to ensure that she was assessed appropriately. However, there were inappropriate delays arranging an MRI scan, to confirm the diagnosis of stroke, and transferring Ms H to the Stroke Unit, which meant that Ms H did not have access to the specialist care and relevant information that should have been available to her. Consequently, Ms H felt her condition and symptoms were not being taken seriously and this increased her stress and distress, which was an injustice. This element of the complaint was upheld to that extent.

We found that the hospital records reflected adequate and appropriate monitoring and documented that Ms H was mostly self-caring in relation to her personal hygiene and toileting needs. Overall, the care provided to Ms H was equivalent to what she would have received on the Stroke Unit, had she been transferred there sooner. Therefore, these elements of the complaint were not upheld.

The Health Board agreed to apologise to Ms H and offer for her to meet with representatives from the ED, Stroke Ward and Hospital Management, to discuss her experience and any further learning that can be taken from it. It also agreed to review its policy and practice for access to MRI scans and ensure that there is clarity on the prioritisation of out-of-hours requests for suspected stroke patients, and to share that with relevant staff. It further agreed to remind staff of relevant guidance on care for patients with suspected, as well as confirmed, stroke, noting that the absence of MRI results should not delay appropriate prioritisation of patients, particularly where they require transfer to the Stroke Unit.

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