PSOW Individual Decisions

Mrs Y complained about the treatment given to her husband, Mr Y, by a GP Practice (“the Practice”) in the area of Aneurin Bevan University Health Board (“the Health Board”) between September 2019 and May 2021. Specifically, Mrs Y complained about the Practice’s management of Mr Y’s open sores, referrals for specialist input (including both Dermatology and Cardiology), medication reviews and complaints handling. The Ombudsman found the Practice’s management of Mr Y’s open sores, the referral to Dermatology, liaising with Cardiology, and the monitoring and review of Mr Y’s medication, were appropriate in the circumstances. Accordingly, these aspects of Mrs Y’s complaint were not upheld. However, the Ombudsman found that the content of the Practice’s complaint responses was not sufficient to address Mrs Y’s concern and were not in line with the PTR Regulations. The failure of the Practice to adequately address Mrs Y’s concerns amounted to an injustice and accordingly, this aspect of Mrs Y’s complaint was upheld. The Ombudsman recommended that the Practice arrange for complaint handling training to be provided to its staff by the Health Board.

Miss B complained about the care and treatment her late father, Mr C, received. In particular, she was unhappy at a GP’s lack of action in relation Mr C’s legs/feet from 2017 onwards, the lack of involvement of the Community Mental Health Team (“CMHT”) with Mr C over the same period, whether Mr C had capacity in relation to a Do Not Attempt Cardiopulmonary Resuscitation (“DNACPR”) order during his final hospital admission, and the delay in the Health Board’s complaint response. The Ombudsman did not uphold Miss B’s complaints. Her investigation found that Mr C’s GPs offered him good care from 2017 onwards, there were no shortcomings in Mr C’s dealings with the Health Board’s CMHT during the same period, Mr C had capacity when he agreed to the DNACPR order, and whilst the Health Board’s complaint response took 14 months, it apologised to Miss B so the Ombudsman took no further action.

Mrs X raised a concern that signs of her late husband’s cancer were missed on a chest X-ray taken in May 2021. He was subsequently diagnosed with advanced cancer in October 2021, and sadly died very soon after. Having sought clinical advice on the scans, the Ombudsman found that there was no evidence of malignancy on the earlier chest X-ray, nor anything that should have prompted follow up investigations. The subsequent scans taken in October 2021, when the diagnosis was made, clearly showed widespread development of tumours in the lungs and liver, indicating an unusually aggressive cancer. As the Ombudsman was satisfied that nothing was missed on the scans, she found no reason to continue the investigation.

Ms A complained that a GP Practice in the area of Aneurin Bevan University Health Board failed to deal with her complaint appropriately. The Ombudsman found that the Practice had provided Ms A with a response, but the response was not in keeping with the Putting Things Right Regulations and that parts of the response were inappropriate in tone or content. This resulted in Ms A feeling that her complaint was not dealt with appropriately and, she said, inflamed her concerns. The Ombudsman contacted the Practice and in resolution of Ms A’s complaint it agreed that within 20 working days, to provide a written apology, acknowledging that parts of the complaint were not investigated or responded to appropriately and that staff would re-familiarise themselves on how to manage complaints under the Regulations. The Ombudsman considered this to be an appropriate resolution and did not investigate.

Ms A complained that her late father had acquired COVID-19 during his admission to Royal Gwent Hospital. The Ombudsman was concerned that the complaint had not been considered under the NHS Wales National Framework, established to consider complaints about hospital acquired COVID-19 infections. She sought and gained the Health Board’s agreement to consider the complaint under the National Framework.

Mr A complained about the standard of care provided to his wife, Mrs A, by a GP Practice in the area of Aneurin Bevan University Health Board. Specifically, Mr A said that his wife should have been offered a face-to-face appointment or examination, rather than a telephone consultation. The Ombudsman found that, although Mrs A was not offered a face-to-face appointment, the action taken by the GP in arranging follow-up investigations for her was appropriate. She also found that although Mrs A was not provided during this appointment, with safety netting advice about how to seek support, she had done so previously and therefore had a good understanding of how to access assistance. The Ombudsman considered that this might not have been the case for other patients, and so took the opportunity to ask the Surgery to consider this as a learning point. The Ombudsman contacted the Practice, and in resolution of Mr A’s complaint, it agreed to, within 20 days, provide Mr and Mrs A with a written apology for the fact that they were unhappy with the care provided to Mrs A and to provide a reminder to all clinical staff to ensure that appropriate safety netting advice is provided to patients during all consultations, whether conducted in person, via telephone or via video call.

Mr B complained that Aneurin Bevan University Health Board failed to provide a response to his complaint which he made in September 2022. Mr B also complained that despite asking the Health Board to address correspondence directly to him, it had failed to do so. The Ombudsman decided that the Health Board had failed to address correspondence directly to Mr B, had not provided regular and meaningful updates, and had not issued a complaint response. She said that this caused frustration and uncertainty to Mr B. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to apologise to Mr B and provide explanations for the delay, lack of regular and meaningful updates and failure to address correspondence to him. The Health Board also agreed to offer Mr B redress of £75 and issue a complaint response within 6 weeks.

Mrs D complained that despite an update being provided by Aneurin Bevan University Health Board in August 2022 that its response was complete and awaiting sign off, she was further informed in January 2023 that further investigations were needed. Mrs D further complained that she had not received a complaint response and had been waiting since July 2022. The Ombudsman decided that there had been a significant delay between the Health Board completing its investigation and issuing its formal written response, which it has still not done. This has caused unnecessary frustration and inconvenience for Mrs D. The Ombudsman decided to settle this complaint without an investigation and sought and gained the Health Board’s agreement to issue its formal written response within 4 weeks, and a time and trouble payment of £250.

Mrs X complained that there was no proper examination or assessment of her late husband, Mr X’s condition during a GP consultation in August 2021. As a result, no appropriate treatment or referral for further investigation was made. Whilst the ultimate diagnosis would not have been altered, the Ombudsman found no evidence to indicate that an appropriate assessment of Mr X’s presenting symptoms, or proper examination, took place during the consultation. The response to the complaint by the GP Practice was also inadequate resulting in Mrs X having to pursue her complaint to the Ombudsman. The Ombudsman upheld the complaint and the following recommendations were agreed: • The GP Practice should review and discuss the complaint at a Significant Event Analysis (SEA) meeting. • The GP Practice should provide a further written apology to Mrs X reflecting the Ombudsman’s findings, and explain the outcome of the SEA meeting. • The GP should discuss the complaint, and his learning from it, at his next annual appraisal. 18 April 2023

Mrs A complained that Aneurin Bevan University Health Board had failed to issue a complaint response to her by the date it had agreed in a previous early resolution with the Ombudsman’s office. The Ombudsman decided there had been a further unacceptable delay in the Health Board responding to Mrs A and this had caused additional frustration to her. The Ombudsman sought and gained the Health Board’s agreement to apologise to Mrs A for the further delay she had experienced, pay her further redress of £100 and provide its complaint response within 4 weeks. The Ombudsman accepted these actions as an alternative to issuing a Special Report.

Mrs B complained about the care provided by the Health Board to her late father, Mr C, in relation to 2 hospital admissions in August and September 2021. Specifically, Mrs B complained that the level of communication with Mr C’s family was inappropriate during his admissions and Mr C was discharged too quickly following his first hospital admission. Mrs B also complained that Mr C’s ability to care for himself at home was not assessed adequately and that a care package should have been arranged prior to his discharge on 8 September. Finally, Mrs B was concerned she was not given enough warning about the seriousness of Mr C’s condition and she was not allowed to see him the day before he died. The investigation found that the Health Board had communicated with Mr C’s family appropriately about his clinical condition and care, but had failed to do so adequately in respect of both the level of assistance he would need from them at home following discharge, and when any professional assistance would commence. The investigation also concluded that the Health Board had failed to adequately assess Mr C’s care needs prior to discharge and, had it done so, it was likely that a care package would have been arranged before he was allowed home. However, the decision to discharge Mr C home from hospital was clinically appropriate as he no longer required treatment in an acute hospital setting. The investigation identified staff could not have foreseen Mr C’s rapid deterioration or have informed Mrs B of the seriousness of his condition at an earlier stage. Finally, the decision not to allow Mrs B to visit Mr C the day before he died was appropriate because his death was unforeseen. The Ombudsman partly upheld Mrs B’s complaint that the level of communication with Mr C’s family was inappropriate during his admissions and upheld her concern that Mr C’s ability to care for himself at home was not assessed adequately and that a care package should have been arranged. The Health Boar

Mr A complained on behalf of his wife, Mrs A, about the care and treatment she received from a GP Surgery (“the Surgery”) which is managed by Aneurin Bevan University Health Board (“the Health Board”). Mr A said that the Surgery failed to respond appropriately when Mrs A became increasingly unwell, which culminated in an emergency admission to hospital. Mr A said that the Surgery also reduced Mrs A’s medication dose in error from what was prescribed in her discharge notes from the hospital. Finally, Mr A also complained about the Health Board’s handling of his complaint which included poor communication and delay in providing a complaint response. The investigation found that the care provided to Mrs A by the Surgery was reasonable and appropriate. Whilst there did appear to have been an error in the Surgery reducing Mrs A’s medication dose, there was no evidence to suggest that it affected Mrs A’s ongoing management or her condition. The Ombudsman did not uphold these complaints. However, the investigation did find that the Health Board unreasonably delayed in responding to Mr A’s complaint and this aspect of Mr A’s complaint was upheld. The Ombudsman recommended that the Health Board apologise to both Mr and Mrs A and pay a sum of £250 for the time and trouble they had experienced in pursuing this complaint. Finally, the Health Board was asked to review its complaint handling procedure and take practical action to ensure that, where a complaint investigation will exceed the timescales set out in the Guidance and Regulations complainants are kept up to date with a meaningful explanation of the reasons for any delay.

Mr H complained about the care provided to his late father, Mr B, during 2 admissions to Royal Gwent Hospital and Ysbyty Ystrad Fawr. The Ombudsman upheld the complaint about an initial decision to discharge Mr B, as he was not medically fit and appropriate plans had not been made, causing worry and distress to Mr B and Mr H. When Mr B was subsequently discharged, the causes of his symptoms had been appropriately investigated and a diagnosis made. The Ombudsman also found no evidence that Mr B had continence needs that should have been addressed, and she did not uphold the complaint. She found that it was appropriate to cancel a MRI scan arranged as an out-patient, but that on the balance of probabilities, Mr B and Mr J were not informed of the decision, resulting in inconvenience to them, and to that extent she upheld the complaint. The Ombudsman did not uphold the complaint about the monitoring of Mr B’s food and fluid intake. She also found that Mr B’s weight loss, diarrhoea and general deterioration were properly investigated, and that his infection was promptly and appropriately treated, and she did not uphold these aspects of the complaint. She considered that it was not unreasonable for Mr B to be left unsupervised in a chair when he was having an episode of rigor, and did not uphold the complaint. However, she found that on the balance of probabilities, Mr H and his uncle were not informed of the seriousness of Mr B’s condition, and that if they had been, the shock of his death might have been lessened, although the explanations subsequently provided by the Health Board were reasonable. She upheld the complaint to a limited extent. She also found that the Health Board did not obtain information about both admissions for discussion at a meeting, resulting in a lost opportunity for Mr H to get answers to his questions, although she acknowledged that the Health Board subsequently made appropriate efforts to resolve the complaint. The Ombudsman also upheld this

Mrs F complained that she had not received any correspondence from Aneurin Bevan University Health Board regarding her complaint since December 2022. The Ombudsman decided that the Health Board had failed to provide regular and meaningful updates. She said this caused frustration and uncertainty to Mrs F. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to apologise to Mrs F and provide appropriate updates whilst her complaint goes through the redress process.

Mr A complained that he had not received appropriate and sufficient support from Aneurin Bevan University Health Board’s (“the Health Board’s”) Community Mental Health Team between December 2019 and September 2020. He also complained that the Health Board had failed to take appropriate account of his complex mental health needs when he attended the Royal Glamorgan Hospital (“the Hospital”) on 1 and 15 June 2020 and failed to discharge him safely. He also complained that the Health Board had failed to respond to his complaint appropriately. The Ombudsman considered that the Health Board had provided Mr A with appropriate and sufficient mental health support from its Community Mental Health Team between December 2019 and September 2020. This element of the complaint was not upheld. In relation to the way that the Health Board took account of Mr A’s complex Mental Health needs, the Ombudsman found it have taken appropriate action although it was invited to consider Mr A’s need for reasonable adjustments in future and to review how it identifies patients with a disability promptly when they attend the Emergency Department. The Ombudsman also found that the Health Board had not failed to discharge Mr A safely since he left the hospital before had been able to formally discharge him. These elements of the complaint were not upheld. In relation to the way in which the Health Board responded to Mr A’s complaint, the Ombudsman found that the Health Board did not give Mr A a joint response to his concerns, took too long to provide its responses and did not fully address Mr A’s concerns about the Hospital in the response provided. The Health Board’s loss of some of Mr A’s hospital records also appears to have impacted on its ability to respond fully to Mr A’s concerns. These complaint handling failings caused Mr A distress, inconvenience and uncertainty, which amount to a significant injustice and led the Ombudsman to uphold the complaint. The Ombudsman recommended that the He

Mr X complained that the Health Board had not provided him with a response to the complaint he submitted to it in October 2021. The Ombudsman decided that there had been a substantial delay in the Health Board’s complaint response, which led Mr X to contact the Ombudsman. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to issue its complaint response and apologise for the delay within 3 weeks. It also agreed to pay Mr X financial redress of £250 in recognition of the time and trouble he had expended.

Ms A complained to the Ombudsman about the care provided to her late mother, Mrs B, at the Royal Gwent Hospital (“the Hospital”) in particular: • that physicians failed to adequately investigate Mrs B’s symptoms of severe abdominal pain, vomiting and weight loss during 2 admissions (from 19 – 20 November and from 26 November to 19 December 2018) • that, on both occasions, Mrs B was discharged with inadequate support (and pain control) and being unable to cope at home, was re-admitted within days • that physicians failed to detect/report an occlusion (blockage) in the superior mesenteric artery (“SMA”) which was visible on CT scans conducted on 19 November and 7 December 2018. Ms A said that this delayed medical treatment and/or surgical intervention and, consequently, questioned whether the outcome of Mrs B’s care and treatment might have been different had the blockage been detected. • Finally, Ms A complained that the Health Board’s handling of her complaint/concern under the Putting Things Right Scheme (“PTR”) was deficient and excessively protracted, and communications with her were poor, infrequent and unhelpful. The Ombudsman found that, although the investigations undertaken during the first and second admission were appropriate, clinicians should have undertaken further investigations during Mrs B’s second admission in the absence of a clear diagnosis for the cause of her unresolved pain. The Ombudsman upheld this complaint to that limited extent. The Ombudsman found that, although the decision to discharge Mrs B from the first admission was appropriate, there was insufficient evidence that clinicians had adequately considered her pain relief requirements. The decision to discharge Mrs B from the second admission was inappropriate and again, clinicians had failed to properly consider her pain relief requirements. The Ombudsman upheld this complaint to that extent. The Ombudsman found that the occlusion identifiable on the first 2CT scans was not reported on,

Mrs A complained about Aneurin Bevan University Health Board’s (“the Health Board’s”) handling of a complaint, submitted in respect of care and treatment provided to her late husband. Mrs A said that she was not informed about the existence of advocacy services which would have assisted her through the complaints process. Further, Mrs A said that the Health Board’s complaint response did not fully address the concerns she raised. The Ombudsman found that the Health Board had failed to notify Mrs A about the availability of advocacy and support services who would have been able to assist her. She also found that the Health Board had not apologised to Mrs A for a failure identified in its investigation in respect of the lack of capacity assessments undertaken. Further, she found that the investigation report did not address a number of issues raised by Mrs A. The Ombudsman contacted the Health Board, and in resolution of Mrs A’s complaint it agreed to, within 20 working days, provide her with an apology and explanation for the failure to provide her with details of advocacy services, provide an apology for the failure to undertaken any capacity assessments of her late husband, provide Mrs A and the Ombudsman with details of the steps taken to improve service provision in respect of ensuring that capacity assessments are completed and provide Mrs A with a further written complaint response which addressed her outstanding issues.

Mrs P complained that multiple failings in the care and treatment provided to her late father, Mr T, by Aneurin Bevan University Health Board at the Royal Gwent Hospital and St Woolos Hospital, resulted in him suffering avoidable pain and distress, hastened his deterioration, and led ultimately and avoidably, to his death from sepsis. The investigation considered Mrs P’s specific complaints that clinicians: • Failed to respond with sufficient urgency (and in accordance with established clinical guidance) to the possibility that Mr T had suffered an ischaemic stroke. • Failed to competently catheterise Mr T resulting in him suffering extreme pain, discomfort and a urinary tract injury which led to infection. • Failed to implement the Health Board’s sepsis protocol in a timely manner. • Failed on numerous occasions, to adequately document and/or act upon significant clinical information in accordance with established procedure (in relation to NEWS charting and escalation, hydration, pain assessment, blood-test results, medication omissions and catheter monitoring). • Failed to competently manage and record the prescription and administration of Mr T’s antibiotic medication. The investigation also considered Mrs P’s complaint about the Health Board’s handling of her complaint and the protracted delay in providing a formal response. The investigation found that the care Mr T received for his suspected stroke was appropriate, timely and in keeping with relevant guidance. Accordingly, the Ombudsman did not uphold that complaint. The investigation found, on balance, that there was a failure to catheterise Mr T appropriately and that this had caused him avoidable pain and distress. For that reason that complaint was upheld. The investigation found that there was a failure to carry out sepsis screening on 4 June which would, at the very least, have provided reassurance to Mr T that he was receiving appropriate care. As a result, that complaint was upheld. The investigation a

Mr X complained about the care provided when he attended the ED with chest pain. The investigation considered whether, given Mr X’s presenting symptoms and clinical cardiac history, appropriate examinations and investigations were undertaken on 17 July 2020, whether there was any indication that Mr X’s symptoms were cardiac in nature and that a heart attack was impending, and whether the diagnosis given to Mr X on 17 July2020 was clinically appropriate. The investigation found that appropriate examinations and investigations were undertaken on 17 July and so this complaint was not upheld. The investigation found there were clear indications that Mr X’s symptoms were cardiac in nature ,but that these symptoms were not properly considered in conjunction with seemingly reassuring test results. However, since it was not possible to say, with any degree of certainty, either that a heart attack was impending or that it could have been avoided, this complaint was only partially upheld. The investigation found that the diagnosis given to Mr X on 17 July, that his symptoms were likely the result of musculoskeletal or acid reflux issues, was not appropriate and so this complaint was upheld. The Health Board agreed to apologise to Mr X for the failings identified and to share the report with clinical staff involved in the care and treatment of patients presenting to ED with chest pain and reiterate the importance of considering patient history alongside test results when reaching a diagnosis.

Mr X complained that the Health Board had not provided him with a response to his complaint regarding an alleged failed knee surgery. The Ombudsman decided that there had been a delay in the Health Board’s complaint response, which caused frustration to Mr X and led him contact the Ombudsman. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to issue its complaint response promptly within 7 working days.

Mrs L complained that despite raising concerns about her mother’s care at the Aneurin Bevan University Health Board, she had not been kept updated, or received a response. The Ombudsman was concerned that Mrs L had not received a response and contacted the Health Board. The Ombudsman concluded that the Health Board failed to comply with its statutory complaints procedure and said that this caused Mrs L frustration. As an alternative to an investigation, the Ombudsman sought and gained the Health Boards agreement to provide Mrs L with an apology for the delay, and an update on the case within 30 working days. It also agreed that it would issue Mrs L with a formal response within 4 months.

Mr A complained about the care and management that his late wife Mrs A received at the Royal Gwent Hospital and the Grange University Hospital during her last admission in December 2020. He questioned why his wife was moved to a COVID-19 ward when she was “low positive” and given insulin when her blood sugar was low and causing hypoglycaemia (low sugar level due to diabetes). Mr A complained that the blood transfusion caused an adverse reaction, and he believed, that the blood did not match his wife’s ethnicity. Mr A also complained about ineffective communication. He felt that the nurses might have been “racist”. Finally, Mr A remained unhappy with the robustness of the Health Board’s complaint response. The Ombudsman’s investigation concluded that it was reasonable and appropriate to have moved Mrs A to a COVID-19 ward when she developed a temperature and after appropriate steps were taken to test for, and diagnose COVID-19. The Ombudsman was also satisfied that Mrs A was treated appropriately with insulin as and when required and that there was no evidence that she was administered the insulin “forcefully” or that she suffered an adverse reaction to the insulin. The Ombudsman found no evidence that there were complications or side effects from Mrs A’s blood transfusion and noted that the donor bloods were tested against Mrs A’s blood sample for matching, and that ethnicity matching was not a requirement for blood transfusion. Accordingly, those aspects of Mr A’s complaint were not upheld. The Ombudsman’s investigation found failings in communication with Mr A and Mrs A. The Ombudsman highlighted that whilst she was unable to make definitive findings about whether discrimination, harassment or victimisation had occurred under the Equality Act, she could comment if she considered it appropriate to do so. She was satisfied that the Health Board’s policy on language and interpreting services was followed. The Ombudsman was critical that communication with Mr and Mrs

Mrs X complained about the care and treatment provided to her late husband by the Health Board in 2021. The initial complaint response did not address all of her concerns and contained discrepancies and inaccuracies. At a meeting in September 2022, it was agreed that the complaint investigation would be revisited and a final response letter would be provided to Mrs X. The Ombudsman found that although some progress had been made, a formal complaint response had not been provided. The Ombudsman decided to settle the complaint without an investigation. The Health Board therefore agreed to, within one month, provide Mrs X with a written apology for its failure to fully investigate her initial concerns and provide a complaint response in relation to outstanding issues. It agreed to make a payment of £150 to Mrs X in recognition of the failings and the unnecessary time, trouble and upset caused in having to raise her complaint with the Health Board and the Ombudsman. It further agreed to, within 2 months, provide Mrs X with a formal written complaint response in respect of the outstanding concerns. The Ombudsman’s view was that the above action was reasonable to settle Mrs X’s complaint.

Mrs L complained that Aneurin Bevan University Health Board failed to provide a response to her concerns which she raised in August 2022. The Ombudsman concluded that the Health Board had failed to act in accordance with its statutory complaint’s procedure. She said this caused frustration to Mrs L. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to apologise to Mrs L and issue a complaint response within 30 working days.