PSOW Individual Decisions

Mr A complained that the GP Practice failed to recognise or respond appropriately to his needs, leading to him being removed from the patient list. The Ombudsman decided that the Practice had not communicated effectively with Mr A and decided to settle the complaint without an investigation. The Ombudsman sought and gained the Practice’s agreement to, within one month, consider how reasonable adjustments might be made to its appointment booking system, ensure that changes to prescribing practice are appropriately communicated and ensure all staff are aware of the process for booking interpreters.

Mrs A complained because she was unhappy with Aneurin Bevan University Health Board’s care and treatment of her late son. Mrs A’s son sadly died in September 2023. The Ombudsman noted that the Health Board had completed a Serious Incident Report which identified points of learning. The Ombudsman decided that the explanations within the report were reasonable. The Health Board provided a complaint response and held a meeting with Mrs A in February 2025. However, the Ombudsman was concerned that the Health Board had failed to take notes of the meeting and failed to provide an update on her son’s medication, as agreed in the meeting. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to, within 3 weeks, apologise to Mrs A for the lack of notes taken in the meeting, to provide an update regarding her son’s medication and to provide an update on the progress of the recommendations from the Serious Incident Report.

Mrs B complained that Aneurin Bevan University Health Board had not responded to the complaint she had originally made to a GP Practice in the Health Board’s area. The Health Board had subsequently taken over the management of the GP Practice. The Ombudsman found that there had been a delay in Mrs B receiving a response to her complaint, which the Ombudsman said caused frustration to her. The Ombudsman decided the settle the complaint without a formal investigation. The Ombudsman sought and gained the Health Board’s agreement to apologise to Mrs B for the delay and explain the reasons for it, to offer a £150 redress payment, and to issue its response to the complaint within 6 weeks.

Mrs X complained that the Practice failed to respond to her complaint that she submitted to it in November 2024. The Ombudsman found that the Practice had failed to respond to Mrs X’s complaint, and it had also failed to regularly update her. She said this caused uncertainty and frustration for Mrs X. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Practice’s agreement to, within 4 weeks, apologise to Mrs X for the delay and for the lack of regular updates, to issue its complaint response and offer her £100 redress payment for the delay, lack of regular updates and for the time and trouble in making a complaint to the Ombudsman.

Mrs P complained about whether the medications given to her late husband (Mr P) during his admission to St Woolas Hospital between August and October 2023, were appropriate. The Ombudsman found that Mr P presented as a complex case and the levels of medication reflected his behaviour and how out of the ordinary it was. Whilst the rationale for prescribing some medication was not always clear within the medical notes, overall, the risks and benefits were sufficiently considered and the medications were appropriate. The complaint was not upheld.

Mrs X complained that Aneurin Bevan University Health Board failed to respond to the complaint she submitted in August 2024. The Ombudsman found that the Health Board failed to provide the formal complaint response. The Ombudsman said this 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 4 weeks, offer an apology to Mrs X for the delay and explain why this happened. In addition to also providing a formal complaint response and offer a £150 financial redress payment in recognition of the delays.

Mrs X complained about the care provided to her late mother by a GP practice in the Aneurin Bevan University Health Board area. The Ombudsman found that the GP Practice held a meeting with Mrs X to discuss her concerns; however, it had failed to provide a complaint response in line with the ‘Putting Things Right’ procedure. She said this had caused uncertainty for Mrs X. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the GP Practice’s agreement to apologise to Mrs X for failing to provide a complaint response, and to issue its response within 2 weeks.

Mrs A complained about the care and treatment provided by Aneurin Bevan University Health Board (‘the Health Board’) in relation to gynaecological issues. Mrs A complained that she attended the Emergency Department on numerous occasions but on each occasion, she was discharged with no plan, answers or understanding of what had happened. Mrs A further complained about her experience during a hospital admission, when she underwent emergency surgery. The Ombudsman found that Mrs A had made 2 complaints, but these had been dealt with by way of early resolution, without an investigation. The follow-up appointment promised did not take place. The referral to gynaecology did not resolve matters and raised further issues for Mrs A. Mrs A has not been provided with a formal complaint response addressing her concerns. This has caused delay, uncertainty and frustration for Mrs A. The Ombudsman agreed to settle the complaint without an investigation. The Health Board agreed to, within 6 weeks, provide Mrs A with a formal complaint response, addressing all concerns raised with the Health Board and the Ombudsman, together with an apology for the failure to formally investigate her concerns previously.

Complained about the care and treatment provided to his mother whilst a patient at GUH in February 2024 and YYF in May 2024. Also complained that the Health Board has not responded to a further complaint submitted about a period of care in June 2024. Complaint was not investigated as could not see evidence that the care and treatment provided to his mother fell below that we would expect from the NHS in Wales. Also, in light of action taken by the Health Board, it would not be proportionate to investigate. Health Board agreed to an early resolution to provide a response to the outstanding complaint and the apologise for the delay in responding.

Ms P complained that Aneurin Bevan University Health Board failed to respond to a complaint she submitted in August 2024. The Ombudsman found there was a significant delay with the Health Board concluding its investigation and that it failed to keep Ms P regularly updated on the progress. This caused additional frustration and uncertainty for Ms P. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to issue its complaint response within 30 working days. It should include an apology and financial payment of £150 in recognition of its failure to keep Ms P updated.

Mrs F complained that Aneurin Bevan University Health Board failed to respond to a complaint about the care and treatment provided to her late husband. The Ombudsman found that the Health Board informed Mrs F, in January 2025, that the investigation was complete but the response was not issued when she brought her complaint to us in April. This caused additional frustration and uncertainty for Mrs F. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to write to Mrs F, within 1 week, to apologise and explain the delay. It also agreed to issue its response within 3 weeks.

Mr A complained about the length of time that he had been waiting for cataract surgery. He was dissatisfied with the Health Board’s response to his complaint. The Ombudsman found that referrals had been made by Mr A’s optician in 2022 and 2024. Although the waiting list for treatment was around 2 years, Mr A had already waited around 2 years and 6 months without being treated. The Health Board had not undertaken a complaint investigation or provided a formal complaint response, despite this having been requested by Mr A. Informal responses provided contained incorrect information and had not adequately addressed matters. This caused frustration and uncertainty for Mr 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, provide Mr A with a formal complaint response, together with an apology and explanation for the errors contained in the Health Board’s informal complaint responses and an update as to the current position in relation to his cataract surgery.

Ms D complained about the waiting times at Aneurin Bevan University Health Board for a knee replacement for her daughter, Mrs E, who had very sadly since passed away. Ms D said that she had sent a letter to the Health Board but had only received a response via her Member of Senedd. The Ombudsman decided that whilst Ms D had written to the Health Board in December 2024, it was not clear that she wanted to raise a complaint. However, it would have been appropriate for the Health Board to have contacted her directly to clarify. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement that within 2 weeks it would write to Ms D to apologise for not acknowledging her correspondence or seeking to clarify whether she wished to complain.

Mrs L complained that Aneurin Bevan University Health Board had arranged an appointment at an incorrect clinic and failed to consider her request to reimburse her for her out of pocket expenses. The Ombudsman found that, although the Health Board had admitted it had sent Mrs L to the incorrect clinic in error and apologised to her, it had failed to consider or respond to her request for her expenses to be reimbursed. The Ombudsman said this caused Mrs L frustration and decided to settle the complaint without a formal investigation. The Ombudsman sought and gained the Health Board’s agreement to apologise to Mrs L for failing to respond to her request for reimbursement and to offer to reimburse her out of pocket expenses, which amounted to £24.50, within 4 weeks.

Mr X complained that Aneurin Bevan University Health Board had failed to respond to his complaint. The Ombudsman decided that there had been a significant delay by the Health Board to respond to Mr X’s complaint. She said this caused inconvenience and frustration for Mr X. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the agreement of the Health Board to provide Mr X with a complaint response that will also include a written apology, explanation for the delays and a redress payment offer of £100 in recognition of the delays by the agreed date.

Following an early resolution of her complaint in 2023, Ms A complained that Aneurin Bevan University Health Board (“the Health Board”) had not contacted her to confirm the outcome of consideration of her father’s case under the NHS Wales National Framework (established to investigate cases of nosocomial (an infection acquired through the delivery of healthcare) transmission of COVID-19). The Ombudsman assessed the case. The Health Board provided evidence that Ms A’s father’s case had been reviewed but said that it had not contacted Ms A to confirm the outcome. The Ombudsman sought and gained the Health Board’s agreement to issue a formal response to Ms A in respect of the consideration of her father’s case under the NHS Wales National Framework. The Health Board also agreed to apologise to Ms A for the delay in providing a response, further to the previous early resolution, and to explain why that delay occurred. The Health Board agreed to complete these actions by 9 June 2025.

Mr A complained that he was unhappy with Aneurin Bevan University Health Board’s response to his complaint about his urology care and treatment. The Ombudsman decided that there was an unnecessary extended delay with the Health Board issuing its complaint response. This resulted in the Health Board informing Mr A that his outstanding concerns could not be considered because they were out of time. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement within one month, to apologise to Mr A, and to provide a response to his outstanding concerns about his care and treatment.

Mrs A complained that Aneurin Bevan University Health Board failed to respond to a complaint she submitted in January 2025. The Ombudsman found that there was a reasonable delay in not issuing a complaint response and the Health Board failed to keep Mrs A updated during the process. This caused additional frustration and uncertainty for Mrs A. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to write to Mrs A within 7 working days with an apology for not keeping her updated. It also agreed to update Mrs A, explain the reasons for the delay and provide monthly updates until the investigation is complete.

Mrs C complained about the care and treatment she received from the Health Board. The investigation considered whether the decision to remove Mrs C’s polyps (abnormal tissue growths) during a colonoscopy (the examination of the inside of the bowels using a thin tube with a light and camera at the end) performed on 31 July 2022 was clinically appropriate. It also considered whether appropriate treatment was provided to Mrs C following the procedure, in particular when she contacted the Health Board on 3 and 4 August 2022 reporting pain. Finally, the investigation considered whether earlier surgical intervention would likely have prevented Mrs C requiring a colostomy (also referred to as a stoma, where one end of the large intestine is diverted through an opening in the abdominal wall). The Ombudsman found that the decision to remove Mrs C’s polyps on 31 July was clinically appropriate, and the procedure was carried out to an appropriate standard. That part of the complaint was not upheld. However, the Ombudsman found that appropriate care and treatment was not provided when Mrs C contacted the Health Board to report pain and discomfort following the procedure, as her symptoms should have prompted her re-admission for assessment, so that her peritonitis (a serious infection of the abdominal tissue) and bowel perforation could have been identified sooner. Furthermore, although she may well still have required surgery and colostomy formation if she had been admitted earlier, the likelihood of this would have been reduced. The delay experienced, and the uncertainty caused, was an injustice to Mrs C, as she will never know if the outcome could have been different. The Ombudsman upheld those parts of the complaint. The Health Board agreed to the Ombudsman’s recommendations that it provide Mrs C with a written apology for the failings identified; to share the investigation report with the relevant endoscopy nurses/Bowel Screening Wales staff, for reflection and learning, re

Ms N complained that Aneurin Bevan University Health Board failed to respond to a complaint, concerning the care and treatment of her mother, that she submitted in January 2025. The Ombudsman found that the Health Board wrote to Ms N in February to advise that the response had been finalised and awaiting approval. This caused additional frustration and uncertainty. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to write to Ms N, within 7 working days, to update her on its progress and to issue monthly updates if the response cannot be issued within 1month.

Mr A complained that the Health Board had disclosed a confidential letter. He further complained about the Health Board’s handling of his complaint. The Ombudsman found that although Mr A had complained to the Health Board, it had dealt with the matter in terms of the data breach only. Responses were provided on behalf of the Health Board’s Information Governance Unit but the Health Board had not considered Mr A’s concerns about the effect of the data breach and/or any safeguarding issues that occurred as a result. This caused frustration and uncertainty for Mr A. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to provide Mr A with a written apology and response within 2 weeks.

Ms C complained about the care and treatment her late mother, Ms A, received from the Health Board when she attended Grange University Hospital (“the Hospital”) in April 2023. The investigation considered whether there was a delay in clinical assessment in the Emergency Department (ED) on arrival at the Hospital on 22 April and, if so, whether this resulted in a delay in diagnosis and treatment of sepsis (including potentially incorrect National Early Warning Score (“NEWS” – a scoring system to detect clinical deterioration) and a delay in the provision of adequate pain relief. In respect of the care and treatment provided between 23 and 24 April when on a surgical assessment unit whether the Health Board appropriately recorded and actioned consciousness levels. The investigation found that there was a delay in a clinical assessment being carried out on Ms A on arrival at the Hospital on 22 April. There were also 2 episodes of incorrect NEWS and a delay in the provision of adequate pain relief. The Ombudsman upheld this aspect of the complaint. We found no evidence to suggest that Ms A’s consciousness levels were not documented correctly and did not uphold this aspect of the complaint. The Ombudsman’s recommendations included the Health Board apologising to Ms C for the failings identified by the investigation and reviewing this case against relevant EG guidance identify any points of learning which can be applied in future care. 11 April 2025

Mr C complained about the care and treatment provided to his late father, Mr A, by the Health Board. Specifically, the investigation considered whether the Health Board diagnosed Mr A’s hip fracture in a timely manner following his admission to the Royal Gwent Hospital on 7 November 2022. The investigation found that Mr A’s complaints of right foot and knee pain were investigated in a timely fashion during his admission. However, given his continued difficulty in mobilising and the reference, by a physiotherapist, that Mr A’s pain could be referred from the hip, it would have been prudent for the Hospital to organise a hip X-ray sooner after Mr A’s admission. It is not possible to state with confidence whether an earlier hip X-ray would have evidenced any fracture. However, the lack of an earlier X-ray represented an injustice to Mr C, as he will retain a lingering doubt as to whether Mr A could have been saved some pain and distress. To this limited extent, the Ombudsman upheld this complaint. The Health Board accepted the Ombudsman’s recommendations and agreed to apologise to Mr C and his family, and remind relevant staff of the importance of carrying out hip X-rays on elderly patients who have a sudden change in their mobility status, which does not improve with therapy.

Mrs A complained that Aneurin Bevan University Health Board had failed to address her concerns raised in August 2024 and had failed to complete a second investigation into the sad death of her son. The Ombudsman obtained further information from the Health Board and decided that although Mrs A was unhappy with the concerns addressed, it had created a significant action plan and maintained correspondence with Mrs A appropriately. The Ombudsman recognised that the second investigation was complex and required contact with clinicians who have left the Health Board. However, the Ombudsman decided that the investigation was ongoing with no indication of when it may be completed. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to provide Mrs A with an apology for the delay and to complete the second investigation within 3 months.

Ms X complained that Aneurin Bevan University Health Board failed to respond to the complaint she submitted in August 2024. The Ombudsman found that the Health Board had failed to respond to the complaint. She said this caused uncertainty and frustration for Ms X. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to, within 2 weeks, write to Ms X with an apology and explanation for the delay and to issue its complaint response.