A man lost his chance of knee surgery after his waiting time was wrongly reset. Now Swansea Bay University Health Board has been rebuked for failing to deliver the changes it promised in response.
After investigators exposed the failings in his case, the board pledged in December to implement their recommendations “within the prescribed timescales”.
The Public Services Ombudsman for Wales says the board failed to complete two agreed recommendations by 12 February 2026: an independent audit to identify other patients affected and training addressing the errors in his case.
More than six months after that deadline, Ombudsman Michelle Morris issued a special report dated 27 August warning that other patients remained at risk of similar waiting-list errors.
She wrote: “I am deeply concerned that this means that other patients remain at risk of their waiting time not being managed in line with the relevant guidance.”
The health board has apologised in a public notice signed by chief executive Abigail Harris and says it accepts the findings and recommendations.
A wait wrongly restarted
The man, identified only as Mr W, complained in January 2025 that he had been waiting for a total knee replacement since August 2019.
Investigators found his waiting-time clock had been inappropriately reset in October 2023. That changed the recorded length of his wait, and he was not told about it.
The investigation found no evidence that a clinician had documented him as medically unfit for surgery. He needed a repeat scan because of how long he had been waiting, and that scan confirmed his fitness to proceed.
The report says the delay left Mr W in pain, with reduced mobility and continuing frustration. He subsequently became unable to undergo the operation.
Earlier checks failed to spot the error
Three earlier investigations, published in January 2024, had already found patients were treated unfairly because of errors in the management of orthopaedic waiting lists. An audit carried out after those findings failed to identify Mr W’s case.
That failure prompted the requirement for an independent re-audit. It was intended to find out whether other patients had incorrect waiting-time reset dates or had not been told their clock had been reset.
The board initially sought to have the work carried out as part of a wider national review. When that arrangement fell through, it turned to NHS Wales Shared Services Partnership Internal Audit.
Progress was then delayed by difficulties extracting and preparing the necessary data. Although preparatory work was under way, the Ombudsman concluded that the audit’s scope was still not finalised and the audit itself had not begun.
On training, the board circulated a case study, but the Ombudsman said it omitted a central finding: Mr W’s clock had been reset without written evidence that a clinician had determined he was medically unfit for surgery.
Accepted the findings, then disputed them
Despite initially accepting the findings in full, the board later disputed whether the requested change to its case study and training matched Welsh Government waiting-time guidance.
The Ombudsman asked it to identify where the guidance allowed a clock to be reset without documented evidence that a patient had been deemed medically unfit. The report says the board did not answer that question and repeated a request for a meeting.
Ms Morris concluded that the board’s changed position had affected its ability to implement the training recommendation. She said it had failed to provide “any meaningful evidence” that the recommendation was being progressed or completed.
In its response to the draft report, the board said it recognised the need for clear clinical documentation and was embedding revised processes before amending its training materials.
Fresh deadlines and another apology
The special report sets new deadlines of four, 12 and 16 weeks. The board is expected to agree the independent audit’s scope and timetable, correct and circulate its case study, and present the report to its board within four weeks.
Within 16 weeks, it should provide the audit findings and evidence that revised training has been implemented. Any patients found to have incorrect waiting-list dates should receive an apology and have their records corrected, with action taken to address the failings identified.
Ms Morris said she would share the report with the board chair, the Cabinet Minister for Health and Care and Healthcare Inspectorate Wales.
In its public notice, the health board said: “The Health Board has accepted the Ombudsman’s findings and recommendations and is committed to implementing the actions identified within the report.”
The notice added: “Swansea Bay University Health Board apologises for the shortcomings identified and remains committed to improving the quality and safety of the services it provides.”
The notice gives no date for completing the overdue work.
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