PSOW Individual Decisions

Mrs X complained that Aneurin Bevan University Health Board failed to respond to the complaint she submitted in April 2025. The Ombudsman found that the Health Board failed to provide Mrs X with a complaint response which the Ombudsman said caused uncertainty and frustration for Mrs X. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to, within 12 weeks, provide a complaint response that will include an apology and explanation for the delays along with a financial redress offer of £150 in recognition of the delays.

Mr C complained about the standard of nutritional care provided to his late father, Mr D, during his admission to Ysbyty Ystrad Fawr. The Ombudsman’s investigation considered whether: • The Health Board took appropriate action to assess and address Mr D’s nutritional care needs. • There were appropriate and timely referrals for review by Speech and Language Therapy, ENT and/or dietetics to address Mr D’s identified nutritional needs. The Ombudsman’s investigation found that there was a delay of 1 week in referring Mr D for dietetic review. This would have enabled assessment of the adequacy of Mr D’s nutritional intake, and earlier consideration of non-oral feeding. It was difficult to conclude that an earlier referral for dietetic review would have altered the outcome for Mr D. However, the Ombudsman accepted that the family’s concern about Mr D’s nutritional management and the resulting uncertainty about whether earlier dietetic review may have improved the outcome for Mr D was itself an injustice. The complaint was therefore upheld to that limited extent. The Health Board agreed to provide an apology to Mr D’s family, and it produced an action plan to promote improvement in nutritional care and monitoring.

Mrs A complained that her adult son, Mr B, who has severe autism, lost access to day services because the Health Board refused to allow him to use a manual wheelchair to access transport. She said that the Health Board had instead offered the use of a powered wheelchair for transit, but she was concerned that the user manual contained a warning against using the chair for this purpose. She said that, in her view, the manual wheelchair is safe to use in transit and that staff should be offered training to use the manual chair appropriately. Having considered information provided by Mrs A and the Health Board, the Ombudsman was concerned that there had been missed opportunities to request a reassessment of the suitability of the powered wheelchair by the Appliance and Limb Advisory Service (“ALAS” – operated by a different health board). It also appeared that the Health Board could have done more to engage with Mrs A to better understand and address her concerns about the use of the powered wheelchair. The Health Board agreed to, within 1 month, request an urgent re-assessment by ALAS of the suitability of the powered wheelchair for Mr B as a means to access transport to day services in comparison to other available options, and to request that it be expedited as far as possible. It also agreed to engage with Mrs A as far as possible pending the outcome of the assessment, regarding her safety concerns about the use of the powered wheelchair and commit that, should those be overcome, it will assist her and her husband to find a storage solution for the wheelchair on their property which is agreeable to them.

Mr B complained that poor communication and inadequate care from Aneurin Bevan University Health Board caused delays in the assessment and treatment of his wife’s sepsis, when she was taken to hospital by ambulance. The Ombudsman decided that the Health Board had not dealt with Mr B’s concerns in accordance with the NHS Concerns, Complaints and Redress arrangements (‘Putting Things Right’). The Health Board and the ambulance service provided separate responses to Mr B’s complaints, which resulted in inconsistencies and omissions in the findings. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to cooperate with the ambulance service and provide a joint complaint response within three months.

Ms A complained about the care and treatment afforded to her child, B, by Aneurin Bevan University Health Board (“the Health Board”). When the Ombudsman looked at the complaint, she was concerned that Ms A said she had not received a report which the Health Board had undertaken to send her in May 2024. The Ombudsman sought and gained the Health Board’s agreement to within 4 weeks, identify the report referred to in the response, provide Ms A with evidence it was shared with her in May 2024, and resend a copy to her. 28 November 2025

Ms C complained about the assessment and treatment provided by an endometriosis nurse working for the Health Board. Specifically, the Ombudsman’s investigation considered whether an assessment and treatment plan by the endometriosis nurse, at an appointment on 14 May 2024, was clinically appropriate. The investigation also considered whether the information shared by the endometriosis nurse in the subsequent multi-disciplinary team (“MDT”) meeting was appropriate. The Ombudsman found that an appropriate assessment was carried out on 14 May and that the treatment plan was also appropriate. The information shared at the MDT meeting on 7 October was also clinically appropriate. Whilst it was acknowledged that this was a distressing and difficult situation for Ms C, there was no evidence that this resulted from a service failure by the Health Board. The complaint was not upheld.

Ms C complained about the assessment and treatment provided by an endometriosis nurse working for the Health Board. Specifically, the Ombudsman’s investigation considered whether an assessment and treatment plan by the endometriosis nurse, at an appointment on 14 May 2024, was clinically appropriate. The investigation also considered whether the information shared by the endometriosis nurse in the subsequent multi-disciplinary team (“MDT”) meeting was appropriate. The Ombudsman found that an appropriate assessment was carried out on 14 May and that the treatment plan was also appropriate. The information shared at the MDT meeting on 7 October was also clinically appropriate. Whilst it was acknowledged that this was a distressing and difficult situation for Ms C, there was no evidence that this resulted from a service failure by the Health Board. The complaint was not upheld.

Mrs X complained that Aneurin Bevan University Health Board failed to respond to the complaint she submitted in February 2025. The Ombudsman found that the Health Board had not provided Mrs X with a final complaint response. The Ombudsman said this caused uncertainty and frustration for Mrs X and decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to, within 10 weeks, provide the final complaint response that will include an apology and explanation for the delays, and an offer of a £150financial redress payment in recognition of the delays.

Ms H complained that Aneurin Bevan University Health Board failed to respond to her complaint, submitted in April 2025, regarding the care her daughter received. The Ombudsman found that there was a delay with the Health Board issuing its complaint response. Although the Health Board kept Ms H updated, it failed to provide reasons for the delay or provide a timeframe for the expected response date. This caused additional frustration for Ms H. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to provide the complaint response within 1 week, along with an apology and explanation for the delay.

Mrs A complained about care and treatment provided to her husband, Mr A, by Cardiff and Vale University Health Board (“the First Health Board”) on behalf of Aneurin Bevan University Health Board (“the Second Health Board”) after he was diagnosed with a brain tumour in 2023. The investigation specifically considered whether Mr A received adequate post-operative care following neurosurgery at University Hospital Wales (“the First Hospital”), including appropriate monitoring and clinical reviews. The investigation found that Mr A received appropriate post-operative medical care. The nursing care was broadly adequate, but there was a failure to document that his identified needs relating to confusion, agitation and behaviour had been met. This complaint was upheld to that limited extent in relation to the care provided by the First Health Board . The investigation also considered whether clinicians at the First Hospital took adequate steps to ensure that Mr A’s care was patient led, taking into account his mental capacity to participate in decision-making and involving family members where appropriate. The investigation found that nursing staff failed to demonstrate that they had appropriately considered Mr A’s mental capacity to consent to nursing interventions. There were several missed opportunities to carry out an adequate mental capacity assessment and to engage with Mr A’s family to ensure that his voice was heard and that he received appropriate patient led care. There was also a failure to communicate adequately with Mrs A after she was prevented by illness from visiting the ward. This complaint was also upheld in relation to the care provided by the First Health Board. The First Health Board agreed to apologise to Mrs A and pay her £750 in recognition of the impact the failings had on Mr A and his family. It also agreed to reinforce learning points relating to nursing documentation with relevant nursing staff and to carry out an audit. This would look at compli

Miss A complained that the time she had waited on an English NHS waiting list for knee surgery had not been transferred to the Welsh equivalent. At assessment, the Ombudsman found that the Health Board’s response to Miss A’s complaint inadequately explained the policies and procedures behind her transfer between the 2 waiting lists. The Health Board agreed, within 4 weeks of the decision letter, to provide a further response to the issues raised by the Complainant that addresses the transfer between waiting lists.

Ms B complained about maternity care provided by the Health Board and the information provided following a scan. Ms B was dissatisfied with the Health Board’s response to her complaint, which she said contained errors. The Ombudsman found that there were communication issues in the information provided to Ms B, which exacerbated her concerns and caused her additional worry during her pregnancy. The Health Board’s complaint response did not adequately address Ms B’s concerns, which caused her anxiety, turmoil and frustration. The Ombudsman decided to settle the complaint without an investigation. The Health Board agreed to, within 6 weeks, provide Ms B with a further complaint response, addressing the concerns raised in her complaint to the Ombudsman, together with a written apology for any errors in the initial complaint response.

Mr S complained that Aneurin Bevan University Health Board failed to issue a response to his complaint, which he made to it in September 2024, regarding excessive wait times for an appointment for his chronic knee pain. The Ombudsman found that the Health Board had failed to issue a complaint response and failed to provide any updates to Mr S. She said this caused frustration and uncertainty to Mr S and decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to issue its complaint response, apologise and explain the reasons for the delay and offer £100 financial redress in recognition of the delays.

Mrs A, on behalf of Mr B, complained to the Health Board on 10 March 2025 regarding the care and treatment that Mr B received from the Health Board. No response had been provided to Mrs A’s complaint by the Health Board after 6 months. The Ombudsman found that the Health Board’s delay in providing a response to Mrs A’s complaint was contrary to the provisions of the Putting Things Right scheme which governs NHS complaints. The Ombudsman proposed, and the Health Board agreed that, within 6 weeks, the Health Board would provide a response to Mrs A’s complaint, including reasons and apologies for the delay.

Mrs A complained on behalf of her late mother about the Health Board’s complaint handling. The Health Board failed to provide a complaint response to a complaint she submitted 7 months earlier. The Ombudsman found that the Health Board failed to provide the formal complaint response. The Ombudsman said this caused uncertainty and frustration for Mrs A. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to, within 4 weeks, offer an apology to Mrs A for the delay and explain why this happened, along with providing a formal complaint response.

Miss A complained about Aneurin Bevan University Health Board’s handling of the complaint she made to it in December 2024 regarding the care and treatment provided to her. The Ombudsman found that there had been a delay in the Health Board responding to Miss A’s complaint which caused frustration to her. The Ombudsman decided to settle the complaint without a formal investigation. The Ombudsman sought and gained the Health Board’s agreement to apologise for the delayed complaint response and to issue the complaint response within 4 weeks.

Miss A complained about the process in obtaining an autism diagnosis for her daughter and about the delay in receiving a response to her complaint (submitted in September 2024) from the Health Board. The Ombudsman found that the Health Board had failed to respond to Miss A’s complaint in a timely manner. The Health Board agreed, within 20 working days of the decision letters, to issue the response to Miss A’s complaint and, as far as is possible, include reasons and apology for delays.

Ms A complained to the Ombudsman that the Health Board had failed to respond to her complaint, submitted in January 2025, despite some 8 months having passed since the complaint was made. The Ombudsman asked – and the Health Board agreed – that, to settle the complaint, the Health Board should provide the response to Ms A’s complaint, including the reasons and an apology for the delays, within 20 working days.

Mr H complained that Aneurin Bevan University Health Board failed to respond to complaints submitted in December 2023 and September 2024. He also complained that it failed to communicate directly with his advocate. The Ombudsman found that there was a significant delay with the Health Board issuing the complaint responses. Since the involvement of her office, the Health Board had issued the response directly to Mr H, however, it failed to communicate this only with his advocate, as per his request. This caused additional frustration for Mr H. The Ombudsman sought and gained the Health Board’s agreement to write to Mr H’s advocate within 2 weeks and to apologise for the delay for communicating with him against his request. It also agreed to offer a £150 financial redress payment.

Mrs C complained about the care and treatment provided to her husband by the Health Board at the Grange University Hospital and the Royal Gwent Hospital before he died. In particular, Mrs C was concerned that a failure to take due consideration of his liver condition contributed to his deterioration. The Ombudsman identified that the Health Board had agreed to arrange a complaints meeting to discuss Mrs C’s outstanding concerns following its formal response to her complaint. However, there appeared to be an unresolved delay in arranging the meeting so the Ombudsman contacted the Health Board. The Health Board agreed that within 1 month, it would: a) Provide a formal apology to Mrs C for the delay in contacting her advocate to arrange a complaint meeting b) Contact Mrs C’s advocate to confirm a time and date for a complaint meeting with appropriate representatives of the Health Board who can answer the outstanding queries provided to the Health Board on 1 July. The dates offered should be as soon as possible and within 6 weeks. The Ombudsman considered that the above actions could help to resolve Mrs C’s complaints, and therefore settled the complaint on this basis, without investigation

Mrs A complained that Aneurin Bevan University Health Board had failed to conclude an investigation or provide a response to her about the care and treatment provided to her late husband, Mr A. The Ombudsman found that the Health Board had commenced a Serious Incident Investigation in April 2024 and there had been a significant delay in the Health Board concluding the investigation and responding to Mrs A. The Ombudsman said this caused frustration to Mrs A and decided to settle the complaint without a formal investigation. The Ombudsman sought and gained the Health Board’s agreement to apologise and explain the reasons for the delay, offer a redress payment of £250 to Mrs A in recognition of the delay, and to issue a complaint response to her compliant with the ‘Putting Things Right’ process within 8 weeks.

Ms C complained that Aneurin Bevan University Health Board failed to respond to a complaint she raised in December 2024. The Ombudsman found that the Health Board had kept Ms C updated but it failed to provide an expected date for conclusion of its investigation. This caused additional frustration and uncertainty for Ms C. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to write to Ms C to provide an expected date for the conclusion of its investigation.

Ms A complained that Aneurin Bevan University Health Board failed to respond to a complaint she submitted in December 2024. The Ombudsman found that the Health Board failed to keep Ms A regularly updated with the progress of its investigation. This caused additional frustration and uncertainty for Ms A. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Boards agreement to issue its complaint response within two weeks.

Ms A complained that Aneurin Bevan University Health Board failed to respond to a complaint she submitted in December 2024. The Ombudsman found that the Health Board failed to keep Ms A regularly updated with the progress of its investigation. This caused additional frustration and uncertainty for Ms A. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Boards agreement to issue its complaint response within two weeks.

Ms A complained that Aneurin Bevan University Health Board (“the Health Board”) failed to recognise and treat her underlying bradycardia when she visited the hospital. The Ombudsman found that Ms A had complained to the Health Board and had several oral conversations with members of staff from the Putting Things Right Team. However the complaint had been closed without providing Ms A with a written response to her complaint. The Ombudsman decided to settle the complaint without an investigation on the basis that within 1 month of issuing the decision letter the Health Board would: • Provide Ms A with a Putting Things Right response to include a comprehensive explanation of why some of the matters were considered out of time and why discretion had not been exercised to consider the complaint. • Provide a written explanation regarding the cardiology aspect of the complaint.