Clinical treatment in hospital : Swansea Bay University Health Board

Mr A complained about the lack of records of an incident when his father sustained a severe fracture during his admission in February 2022 to a mental health facility.

The Ombudsman was concerned that inadequacies in the record keeping, which were against routine practice and the principles of good administration, meant Mr A had not been provided with an accurate description of what happened and his complaint could not be satisfactorily addressed. This had led to uncertainty which would result in an ongoing injustice to Mr A.

The Ombudsman sought and obtained the Health Board’s agreement to, within 1 month, provide a formal apology for the record keeping failings, offer a payment of £500 in recognition of the lasting uncertainty caused and to remind staff of the importance of accurate record keeping, particularly in cases where patients, who are under assessment for mental health issues, may not be able to later recall information about such incidents.