Source · PSOW (Public Services Ombudsman for Wales)

Swansea Bay University Health Board

PSOW (Public Services Ombudsman for Wales) Resolved / Early Resolution Reference PSOW-202504068 Sector Health Category Medication; Prescription dispensing Decided 30 October 2025

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Miss A complained that the Health Board prescribed and administered the incorrect dose of epilepsy medication to her 3-year old daughter when she attended the Emergency Department. Miss A said that despite having evidence of the prescribed medication, the Health Board said that there was no record of a prescription being given to her daughter. Miss A said that the Health Board did not respond to her request for a meeting to discuss her complaint.

The Ombudsman decided that the Health Board had not explained to Miss A that medication was supplied by the Pharmacy for inpatient use. The Health Board had not identified that seemingly the inpatient medication was taken home when Miss A’s daughter was discharged, or that Miss A had raised concerns that the dose was incorrect. The Health Board said that it tried to contact Miss A to arrange a meeting but had been unsuccessful. The Ombudsman decided to settle the complaint without an investigation.

The Ombudsman sought and gained the Health Board’s agreement to within 4 weeks provide a written response to Miss A, to offer an apology for any confusion caused between inpatient and take home medication, to confirm if any medication administered was at the correct dose, to establish what happened with the medication and remedy any issues identified, and to offer a meeting to discuss the complaint.

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