PSOW Individual Decisions

Miss I complained that Aneurin Bevan University Health Board had failed to provide a response to the complaint she made in February 2022. The Ombudsman found that the Health Board had not provided a complaint response and there had been a delay in identifying the need to obtain consent to access medical records from an alternative health board. The Ombudsman sought and gained the Health Boards agreement to provide monthly updates to Miss I.

Mrs D complained that Aneurin Bevan University Health Board had failed to adequately address her concerns about the treatment provided to her. The Ombudsman decided that the Health Board had delayed logging Mrs D’s further concerns. She said this caused frustration for Mrs D. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to apologise to Mrs D, provide an explanation for the delay and issue a complaint response within 6 weeks.

Ms B complained that for an 8-month period, a GP Practice in the area of Aneurin Bevan University Health Board (“the Practice”) failed to offer her an in-person consultation and appropriate care and treatment for nasal and breathing problems. She since had received a cancer diagnosis. Sadly, Ms B died before the conclusion of the investigation. The Ombudsman found that although Ms B should have been offered an in-person GP consultation during the 8-month period, it was not likely that it would have necessitated a referral or alternative care and treatment at that time. Therefore, the level of injustice was limited. There was no evidence that Ms B reported symptoms to the Practice that should have resulted in an urgent chest X-ray referral. There was no evidence to suggest that the Practice should have suspected that Ms B had lung cancer, or to have initiated investigations that may have detected it – even with the benefit of hindsight. Although a review identified shortcomings in the Practice’s standard of record keeping, which the Practice was asked to reflect upon, this did not clinically impact the outcome for Ms B. The Ombudsman did not uphold the complaint.

Mr and Mrs L complained that Aneurin Beavan UniversityHealth Board failed to issue its final report following a Serious Incident Investigation,despite raising concerns in April 2022. The Ombudsman concluded that the Health Board had failed toprovide regular and meaningful updates to Mr and Mrs L and had failed to complywith its statutory complaint’s procedure. She said that this caused distress toMr and Mrs L. it As an alternative to an investigation, The Ombudsman sought and gained the Health Board’s agreement to apologise to Mr and Mrs L, pay them redress of £50, and provide a complaint response within30 working days.

Mrs B complained about care provided to her mother, Mrs C, by the Health Board following her admission to the Royal Gwent Hospital in October 2020. Specifically, she was concerned that: a) The Health Board failed to appropriately assess and treat Mrs C’s continence needs in order to enable a timely discharge. b) There was a failure by medical staff to involve Mrs B, holder of a Lasting Power of Attorney, in discussions about Mrs C’s medical needs as required by the Health Board’s dementia policy. c) There was a failure to provide appropriate care to Mrs C after she was placed on an end-of-life care pathway. The investigation found that the Health Board did not miss opportunities to discharge Mrs C. However, the first part of the complaint was upheld to the limited extent that there was a failure to consider how to manage Mrs C’s constipation and provide earlier treatment that might have eased her symptoms. The investigation found that there had been a failure to communicate appropriately with Mrs B about Mrs C’s condition after 5 November which negatively affected the care provided. Accordingly, that part of the complaint was also upheld. The Ombudsman did not uphold the complaint about Mrs C’s end of life care, because the investigation found that the care provided was appropriate and in keeping with relevant guidance. The Ombudsman recommended that the Health Board should apologise to Mrs B for its failings and provide reminders to relevant nursing staff of expected standards in relation to dementia and hydration care. The Ombudsman also recommended that the Health Board should remind relevant doctors of the importance of appropriately managing bowel health and of communicating well with the families of patients with dementia.

Ms P complained that Aneurin Bevan University Health Board had failed to provide her with a response to the complaint she made in April 2022. The Ombudsman decided that there had been a significant delay by the Health Board to respond to the complaint and this had caused inconvenience and frustration for Ms P. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to apologise to Ms P and pay her redress of £100 in recognition of the delays. The Health Board also agreed to issue the complaint response within 4 weeks.

Mr L complained that despite making a complaint to Aneurin Bevan University Health Board in September 2022, he had not received a response. The Ombudsman concluded that the Health Board had failed to comply with its statutory complaint’s procedure, and that this caused Mr L unnecessary delays and frustration. As an alternative to an investigation, the Ombudsman sought the Health Board’s agreement that it would provide Mr L with an apology and explanation for the delays within 30 working days, and issue a formal response within 3 months.

Mrs Y complained about the care and treatment provided to her late husband, Mr Y, at Ysbyty Ystrad Fawr (“the Hospital”) between 18 January and 5 February 2021 when he sadly died. The investigation considered whether there was a failure to provide appropriate levels of care in relation to hydration, nutrition and medication administration; whether there was a delay in administering antibiotics on 23 January when sepsis was documented as suspected, and again on 1 and 2 February following difficulties re-cannulating Mr Y; whether the administration of anticipatory medicine was clinically appropriate and whether communication with Mrs Y, when she was unable to visit Mr Y due to COVID-19 restrictions, was appropriate. The Ombudsman found that Mr Y received appropriate levels of care in relation to hydration, nutrition and medication. She found that there was no delay in administering antibiotics on 23 January (sepsis was not present), and whilst there was a delay on 1 and 2 February due to difficulties cannulating Mr Y, there was no undue negative impact on Mr Y from missing 2 doses of antibiotics. The Ombudsman found that it was clinically appropriate to administer anticipatory medication and that the level of communication and explanations provided to Mrs Y about Mr Y’s condition were appropriate. The Ombudsman did not uphold Mrs Y’s complaints.

Mr X complained about the gastroenterology care and treatment he received by the Health Board. The investigation considered whether there was a failure to diagnose Mr X with Coeliac Disease (a condition where the immune system attacks the body’s tissues when gluten is eaten which damages the small intestine so that the body is unable to take in nutrients) in a timely and appropriate manner. The Ombudsman found that as Mr X (who has type 1 diabetes) was presenting with new onset bowel symptoms, and that Coeliac Disease is a well-known association of type 1 diabetes, that it should have been considered as a possible cause of Mr X’s symptoms. She found that consideration should have been given to carrying out a tTG test (used for screening and detecting Coeliac Disease) and that this would have been in line with the requirements of relevant guidance on the diagnosis of Coeliac Disease. Mr X was not tested and this was a service failure and contrary to the requirements of relevant guidance which caused Mr X an injustice as it delayed the diagnosis of the cause of his bowel symptoms. The Ombudsman upheld Mr X’s complaint. The Health Board agreed to implement the Ombudsman’s recommendations to apologise to Mr X, to make a financial redress payment for the distress caused by the delay, to share the report for learning with relevant clinicians and to review relevant pre-assessment documentation to consider including further information to identify appropriate tests.

Mrs A raised a number of concerns on behalf of her late father, Mr B, about the care and treatment provided by the Health Board in September 2021 following his cancer diagnosis. Whilst some of Mrs A’s concerns did not meet the requirements for an investigation by the Ombudsman, the Health Board had not provided a robust response to 2 issues. These were that the Health Board had: • arranged an ambulance transfer between hospital sites contrary to Mr B’s wishes during which he was unnecessarily immobilised on an inflatable stretcher causing confusion and distress • initiated a poorly timed, insensitive discussion with Mr B about whether he wanted to receive cardiopulmonary resuscitation (CPR) in the event of cardiac arrest and did not take his views into account. The Ombudsman contacted the Health Board and, in order to settle the complaint, it agreed provide a more considered response to the first issue and to share Mrs A’s complaint with the doctor who spoke to Mr B about CPR to provide an opportunity for learning and reflective practice.

Mrs A complained about her late husband’s management and care during his inpatient admission to the Royal Gwent Hospital (“the Hospital”) in late December 2019. Her complaint centred on the failure to administer the medication brivaracetam (used to prevent or reduce the severity of seizures) and the effects this had on her husband. She was concerned that when it was re-introduced, the dosage was too high and contributed to his subsequent fall. She also had issues with her husband’s nursing care, and felt the nursing records had not reflected her husband being at the end of his life, meaning a hospice referral was not made by the Palliative Care Team. Finally, Mrs A was dissatisfied with the Health Board’s handling of her complaint and the robustness of its complaint response. The Ombudsman concluded that there was a clear failure to administer brivaracetam to Mr A, an essential medication for the management of his seizures. Administratively, the fact that the Health Board’s medication policy was not followed, meant the situation continued for longer than it might have. Despite this, the Ombudsman was satisfied that clinically Mr A’s outcome was not affected and that the confusion he experienced both before and after brivaracetam was re-introduced was primarily indicative of the progression of Mr A’s brain tumour. The Ombudsman found that the administration failings had caused Mrs A an injustice, since it added to Mrs A’s anxiety and concerns over her husband’s management at a difficult time for the family. To that limited extent the Ombudsman upheld this part of Mrs A’s complaint. In terms of wider care, while the Ombudsman concluded that the nursing care Mr A received was broadly reasonable and appropriate, nevertheless, the investigation identified episodes of care (for example around Mr A’s falls management including documentation, and an occasion where Mr A’s incontinence hygiene needs were delayed), where deficiencies occurred. To that limited extent these part

The investigation considered Ms A’s complaint about her treatment by a GP Practice (“the Practice”), in the area of Aneurin Bevan University Health Board (“the Health Board”). Ms A said she reported to the Practice’s Advanced Mental Health Nurse Practitioner (“AMHNP”), on 15 October 2020, that she was experiencing an adverse reaction to sertraline (a type of antidepressant). However, the AMHNP failed to advise her to discontinue the medication or act upon the deterioration in Ms A’s mental health. Ms A said that the AMHNP failed to schedule a follow-up appointment and arrange blood tests to investigate her symptoms. Ms A said that the AMHNP did, in due course, advise her to discontinue sertraline, but this was done rapidly and she developed symptoms as a result of the discontinuation. Ms A said that the AMHNP failed to acknowledge and respond to her mental health crisis and reacted to her having an aggressive outburst by calling the Police and escorting her from the Practice. Ms A said she was removed from the Practice with immediate effect and considered this response to be inappropriate and unwarranted as her outburst was a manifestation of her illness. The investigation found that Ms A was exhibiting symptoms of depression on 15 October and it was therefore appropriate not to discontinue sertraline. It was also reasonable for a definitive follow-up date not to be booked following the 15 October appointment. The AMHNP was not directed to arrange blood tests by the GP and therefore she could not be criticised for not doing so. The Practice was however, invited to remind the GPs of the obligations placed upon them by the General Medical Council’s ethical guidance for doctors. The clinical decision to cease the prescription of sertraline by gradual reduction on 1 December was appropriate. Whilst the speed of reduction was not in line with the prescribing guidance the impact of the side effects from continuation over a longer period was likely to have been clinically

Mr B complained about the care and treatment provided to him by the Health Board. Specifically he complained that: a) During his admission to hospital in March 2020 there was a failure to provide adequate support for his toileting needs. b) On 1 April 2020 there was a failure to obtain and appropriately document his informed consent prior to inserting a catheter. c) The Community Nursing Team failed to provide appropriate catheter care after his discharge from hospital on 11 April 2020. In response to the Ombudsman’s investigation, the Health Board acknowledged that a number of failings had occurred with regard to the catheter care provided to Mr B. Having taken into account all the available evidence, including clinical advice, the Ombudsman contacted the Health Board to propose a settlement of the complaint. The Health Board agreed to a number of actions, including apologising to Mr B for the failings identified in the catheter care and making a payment of £500 to him in respect of the avoidable discomfort and distress he experienced as a result. It also agreed to provide relevant reminders to all district nurses about service expectations to ensure that similar failings did not occur again. The Ombudsman was satisfied, following consultation with Mr B and his wife, that it was appropriate to settle the complaint on the basis of the agreed actions as it was unlikely that continuing the investigation would achieve anything further.

Miss D complained about the care and treatment her father, Mr E, received following his admission to the Royal Gwent Hospital on 11 October 2020, and during his time at Ysbyty Ystrad Fawr until his death on 12 December 2020. In particular, Miss D was unhappy with the prescription and dosage of risperidone (an antipsychotic drug to help with symptoms of dementia) Mr E received, the amount of time Mr E spent on the COVID-19 ward, poor communication with Miss D in relation to Mr E having a fall and not receiving regular updates on Mr E’s condition, not being informed Mr E had pneumonia and the standard of nursing care especially in relation to Mr E’s personal hygiene and his fluid intake. The Ombudsman’s investigation found that Mr E’s dosage of risperidone was appropriately managed, that he only remained on a COVID-19 ward while he returned a positive swab and he was moved the moment his test was negative, that communication between staff and Miss D was appropriate, and that Miss D was informed Mr E had a chest infection and that he was on a course of antibiotics. The Ombudsman did not uphold these elements of the complaint. However, the Ombudsman concluded that the nursing care Mr E received was inconsistent and that relevant national guidance was not always adhered to. Assessments were not carried out and an individualised plan of care was not completed upon his admission. Mr E’s fluid intake was recorded but either intermittently or in no detail. These shortcomings amounted to service failures that caused Mr E the injustice of having nursing care that did not meet the required national guidelines. This aspect of the complaint was upheld. The Ombudsman recommended that the Health Board should apologise to Miss D for the service failures identified, and that it should share the report with the nursing staff involved in Mr E’s care to discuss the identified failings and to update the Ombudsman’s office with the improvements it plans to implement as a result. The Healt

Mr X complained that he had not received a complaint response following his complaint to the Surgery in July 2022 about his difficulty in getting an appointment with a doctor. The Ombudsman found that the Surgery had not issued a complaint response and had failed to provide regular and meaningful updates to Mr X. The Surgery agreed to write to Mr X with an apology and explanation for the lack of regular and meaningful updates and issue its complaint response within 4 weeks, as an alternative to the Ombudsman investigating it.

Mr X complained that the Health Board refused to commence Life Story Work until he was in a stable placement. The Ombudsman noted that Life Story Work formed part of a Court Order and advised Mr X that he should report a potential breach of the Order to the Court. The Ombudsman sought and agreed with the Health Board that it would write to Mr X within one calendar month with a meaningful update on its position and explain why it cannot offer Life Story Work.

Ms X complained about the decision to assess her father, Mr X, under the Mental Health Act and the way in which it was conducted. She also complained about the failure to identify that Mr X’s hearing aids were missing upon admission to hospital. Finally, she complained about some of the medication he was prescribed during his admission and also about some symptoms which developed while he was in hospital. The Ombudsman was satisfied that the decision to assess Mr X was appropriate and was undertaken adequately. However, the Ombudsman was concerned that the issue of Mr X’s hearing aids had not been properly addressed nor had Ms X’s concerns about how he developed additional health problems in hospital. The Health Board agreed, within 20 working days, to write to Ms X to apologise for failing to identify the missing hearing aids, explain how it would prevent a reoccurrence and provide a further explanation in relation to his medication and health problems while in hospital. The Ombudsman considered this to be an appropriate resolution and did not investigate.

Ms A complained about her diagnosis and treatment by the GP Practice while she was going through a mental health crisis. The investigation considered whether the appointments provided to her were suitable, whether the Practice’s communication with Ms A regarding her requests for appointments was appropriate, whether the medications prescribed to Ms A were appropriate, and whether she was given timely support from the Practice in relation to her withdrawal plan from diazepam (a medication used to treat anxiety and agitation). The investigation found that Ms A was given appointments in line with the Practice’s policies, and that the communication with Ms A about her appointments was appropriate. It found the reduction of Ms A’s citalopram (a medication used to treat depression) was in line with relevant guidelines. Whilst the diazepam was prescribed for a longer period than recommended, this was justified given Ms A’s distress while waiting to be seen by support services, and that sufficient information regarding the potential of addiction to diazepam was provided to her. The investigation found that Ms A’s withdrawal of diazepam was also managed appropriately, and her complaints were therefore not upheld.

Mr X complained about the lack of communication and updates received from the Health Board concerning the care and treatment of his father. The Ombudsman was concerned to note that the Health Board had not communicated with Mr X following a holding letter dated 29 November 2021. To resolve this complaint, the Ombudsman sought and obtained the Health Board’s agreement to apologise for failing to communicate appropriately with Mr X during its investigation, to make a payment of £250 to Mr X in recognition of that failing and to provide monthly update letters to Mr X until a date for the Redress Panel hearing could be given.

Ms S complained that there had been communication failures regarding her concerns, and that she had had no communication from the Health Board since July 2022. Ms S further complained that despite contacting the Health Board for an update, no response had been issued to date. The Ombudsman was concerned that Ms S had not yet received a response to her concerns and contacted the Health Board. The Ombudsman sought and obtained the Health Board’s agreement to provide Ms S with an apology and a formal response within 30 working days.

Mr X’s complaint concerned his medication for Diabetes. Although he had received a complaints response from the Surgery, he remained dissatisfied. The Ombudsman noted the Surgery had provided a reasonable explanation to several of the points raised by Mr X. However, it had not had the opportunity to respond to concerns about the frequency of blood screening, or medication which Mr X said affected his mood. The Ombudsman considered these issues were outstanding and it would be helpful for Mr X to receive a written response from the Surgery. The Ombudsman sought and gained the Surgery’s agreement to provide a response to the outstanding issues within 30 working days

Ms X complained about the investigations, diagnosis and treatment by the Orthopaedic department after she injured her leg during a fall. She was concerned that the Health Board had not properly responded to the complaint and that she was experiencing ongoing problems. The Ombudsman found that there were aspects of the complaint that the Health Board had not responded to. The Health Board therefore agreed to the following: 1. It will provide a further response to Ms X within 30 working days of the date of this letter (covering issues outlined in further detail in the decision letter). 2. The Health Board also reiteratied its offer to refer Ms X for a second orthopaedic opinion concerning the current working diagnosis and any proposed treatment.

Mrs X had a 20 year history of myasthenia gravis (muscle weakness that caused swallowing difficulties). On 6 November 2019 Mrs X was diagnosed with cancer of the tongue with no curative option. On 25 November she was taken by ambulance to the Royal Gwent Hospital (“the Hospital”) because of her swallowing issues. At the Hospital it was noted that Mrs X’s swallow was weaker, she had choking episodes and was unable to spit. Her blood pressure was slightly low but all her observations were within the normal range. Mrs X was advised to go home with a suction machine and she was discharged for a follow-up appointment at the Cancer Centre the next day. On 26 November Mrs X’s condition at home deteriorated, the out of hours GP (“OOHGP”) was called at 03:14. An OOHGP attended, Mrs X was afraid to sleep as she might choke, she was exhausted but not in pain. It was explained that both tongue cancer and myasthenia could obstruct the airway. She was advised to continue with suction as required and palliative Hyoscine patch (used to decrease saliva) until a palliative review later that day at 09:00. It was agreed to continue with this treatment until the palliative review. The OOHGP recognised Mrs X was terminally ill, but had not expected her to die that morning. Sadly, Mrs X died at 04:55. Mrs Y complained about whether her late mother, Mrs X had an appropriate amount of support and care at home before her discharge, the treatment Mrs X received from the OOHGP and that the Health Board had not responded to her complaint about the OOH service. The Ombudsman found that as Mrs X was managed at home with family support, the provision of a full care package did not have to be explored; this aspect of the complaint was not upheld. The Ombudsman also found that the OOH service Mrs X received was reasonable and this aspect of the was not upheld. The Ombudsman found that the Health Board should have included its investigations into the out of hours service in its complaint response. Th

The Ombudsman found that the concerns were investigated and responded to by the Health Board. The Health Board’s response stated that the Dental Practice had apologised to Mr X, but he said it had not. Following contact from the Ombudsman’s office, the Dental Practice agreed, and immediately took action, to formally write to Mr X to offer its apologies directly to him. The Ombudsman was satisfied that a direct apology had been provided and complaint was therefore resolved.

Mrs B complained about her late husband, Mr B’s treatment for cancer in hospital. She complained that Mr B developed a pressure sore due to the hospital’s failure to re-position him sufficiently, and that when the sore was treated with a specialist therapy dressing (“VAC therapy”), it was not appropriately maintained as staff were not trained to use it. She also complained that there was a delay in the Health Board realising Mr B developed sepsis, that Mr B did not receive daily physiotherapy during his time in hospital, that he was left without pain relief medication on 2 occasions, and that there was an unnecessary delay in discharging him home. The investigation found that there were 2 occasions whereby Mr B’s pain relief medication was not refilled in a timely manner, 1 of which may have left him without pain relief for several hours. This complaint was therefore upheld as an injustice to Mr B, however it was noted that the Health Board had since implemented learning procedures to address this issue. The investigation also found that while Mr B had 3 episodes of suspected sepsis, there was only evidence to suggest that there may have been a slight delay of just over 1 hour in treating the first instance, rather than the delay of several days Mrs B was concerned had been the case. This complaint was therefore partly upheld. The investigation found that the evidence available suggested the pressure sore developed when Mr B was transferred to a specialist centre for chemotherapy treatment, and that after he was transferred back to the hospital the sore was treated appropriately. It found that while not all nurses were trained in using the specialist VAC therapy, it was monitored and changed sufficiently often, and there were specialist staff available, even if not immediately accessible on the ward. The investigation found that due to the seriousness and location of the pressure sore, Mr B’s several bouts of sepsis, and the later discovery that his cancer had sprea