PSOW Individual Decisions

Miss X complained that the surgery failed to respond to her complaint regarding several concerns. The Ombudsman found that the surgery had failed to respond to Miss X’s complaint. The Ombudsman stated that this caused uncertainty and frustration for Miss X. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Surgery’s agreement to, within 3 weeks, offer Miss X an apology and explanation for the delay and to issues its complaint response.

Mrs B complained about whether Aneurin Bevan University Health Board took adequate steps to investigate and respond to an allegation that a member of agency staff provider her husband, Mr B, with unprescribed medication on 8 February 2024. The investigation found that the Health Board took adequate steps to investigate and respond to the allegation that a member of staff provided Mr B with unprescribed medication. The Ombudsman did not uphold the complaint.

Mrs M complained that Aneurin Bevan University Health Board had failed to respond to the complaint she submitted in September 2024. The Ombudsman decided that there had delays by the Health Board to provide Mrs M with a response. She said this had caused frustration and uncertainty for Mrs M. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to apologise to Mrs M and provide her with an explanation for the delays. The Health Board also agreed to provide Mrs M with a redress payment of £50 and to issue a complaint response within 4 weeks.

Mrs C complained about Aneurin Bevan University Health Board (“the Health Board”) and a registered Residential Care Provider (“the Care Provider”) which the Health Board had commissioned to provide care to her son, Mr A. The investigation looked at whether between November 2021 and October 2022, the Health Board failed to ensure that the needs stated in Mr A’s care plan were met by the Care Provider. In relation to the Care Provider, whether between November 2021 and October 2022 the Care Provider failed to ensure that it fully met Mr A’s needs, including those stated in his care plan. The Ombudsman found that, overall, there was evidence of good collaboration and monitoring between the Health Board and the Care Provider. This was evidenced through regular reviews, which played an important part in the monitoring process and ensured that a placement met Mr A’s individual needs. The investigation found that TEACCH (originally stood for “Treatment and Education of Autistic and related Communications Handicapped Children”. In its current form TEACCH stands for “Training, Expanding, Appreciating Collaborating and Co-operating and Holistic) in its purest form, was not used to manage Mr A, as the Health Board had confirmed that its standard practice was to use PBS (Positive Behaviour Support. PBS is a person-centred framework for providing long term support to people with a learning disability, and/or autism). This aspect of Mrs C’s complaint was not upheld. The investigation found that whilst Mr A’s placement was not entirely based on the purest TEACCH model, there was evidence that principles of TEACCH were being used alongside PBS and we were satisfied that the Care Provider met Mr A’s needs as set out in his care plan. Therefore we did not uphold this aspect of Mrs C’s complaint.

Mrs C complained about Aneurin Bevan University Health Board (“the Health Board”) and a registered Residential Care Provider (“the Care Provider”) which the Health Board had commissioned to provide care to her son, Mr A. The investigation looked at whether between November 2021 and October 2022, the Health Board failed to ensure that the needs stated in Mr A’s care plan were met by the Care Provider. In relation to the Care Provider, whether between November 2021 and October 2022 the Care Provider failed to ensure that it fully met Mr A’s needs, including those stated in his care plan. The Ombudsman found that, overall, there was evidence of good collaboration and monitoring between the Health Board and the Care Provider. This was evidenced through regular reviews, which played an important part in the monitoring process and ensured that a placement met Mr A’s individual needs. The investigation found that TEACCH (originally stood for “Treatment and Education of Autistic and related Communications Handicapped Children”. In its current form TEACCH stands for “Training, Expanding, Appreciating Collaborating and Co-operating and Holistic) in its purest form, was not used to manage Mr A, as the Health Board had confirmed that its standard practice was to use PBS (Positive Behaviour Support. PBS is a person-centred framework for providing long term support to people with a learning disability, and/or autism). This aspect of Mrs C’s complaint was not upheld. The investigation found that whilst Mr A’s placement was not entirely based on the purest TEACCH model, there was evidence that principles of TEACCH were being used alongside PBS and we were satisfied that the Care Provider met Mr A’s needs as set out in his care plan. Therefore we did not uphold this aspect of Mrs C’s complaint.

Mrs X complained that Aneurin Bevan University Health Board failed to respond to the complaint she made to it in July 2024. The Ombudsman found that the Health Board had not responded to the complaint or kept Mrs X updated during its investigation, which caused frustration to Mrs X. The Ombudsman decided to settle the complaint without a formal investigation. The Ombudsman sought and gained the Health Board’s agreement to apologise to Mrs X and explain the reasons for the delay, to issue the complaint response, and to offer Mrs X a £100 redress payment within 4 weeks.

Ms B complained that despite assurance from Aneurin Bevan University Health Board that she would receive a complaint response from her GP Practice, which was under the responsibility of the Health Board at the time of events, she was informed her complaint was out of time. The Ombudsman decided that Ms B had submitted a complaint to the Health Board about the actions of her GP within the appropriate timescales and had been given assurance that she would receive a response. She had therefore suffered an injustice when she was later informed that her complaint was out of time. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to apologise to Ms B and to provide her with a response to concerns about her GP, within six weeks.

Miss Q complained that Aneurin Bevan University Health Board had failed to respond to the complaint she submitted in June 2024. The Ombudsman decided that there had been a significant delay by the Health Board to provide Miss Q with a response. She said this had caused frustration and uncertainty for Miss Q. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to provide Miss Q with a written apology, £150 redress in recognition of the delays and to issue a complaint response within 3 weeks.

Mr X complained that the Health Board failed to respond to his complaint submitted to it in June 2024. He further complained about lack of regular updates. The Ombudsman concluded that the Health Board had failed to formally respond to Mr X’s complaint, and it failed to provide regular updates in compliance with its complaint process. The Ombudsman said the lack of response and lack of regular updates caused uncertainty, frustration, and inconvenience to Mr X. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to issue Mr X with a complaint response within 2 weeks. The response should also include an apology and explanation for the delay, and lack of regular updates. Furthermore, a redress payment of £100 should be offered for the delay, lack of updates and need to approach the Ombudsman.

Ms B complained to Aneurin Bevan University Health Board regarding the treatment her father received while in hospital. The Ombudsman found that the Health Board had failed to provide a formal complaint response to Ms B and only responded informally. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to apologise to Ms B for not addressing her concerns via the formal complaints procedure and provide an explanation as to why this happened. The Health Board also agreed to issue the formal complaints response within 5 weeks.

Miss T complained that the Surgery had failed to respond to the complaint she submitted in May 2024. The Ombudsman decided that there had been a significant delay by the Surgery to provide Miss T with a response. She said this had caused frustration and uncertainty for Miss T. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the agreement of the Surgery to provide Miss T with a written apology and explanation for the delays, £150 redress in recognition of the delays and to issue a complaint response within 2 weeks.

Mr C complained that Aneurin Bevan University Health Board had failed to respond to the complaint he submitted in May 2024. The Ombudsman decided that there had been a significant delay by the Health Board to provide Mr C with a response. She said this had caused frustration and uncertainty for Mr C. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to provide Mr C with a written apology, £150 redress in recognition of the delays and to issue a complaint response within 8 weeks.

Mrs X complained that Aneurin Bevan University Health Board failed to respond to his complaint that was submitted to it in June 2024. The Ombudsman concluded that whilst the Health Board had issued several holding letters, it had failed to provide a formal complaint response in line with its internal complaint process. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to issue its formal complaint response within 6 weeks of the Ombudsman’s decision. The decision should also include an apology and explanation for the delay.

Mr X complained that Aneurin Bevan University Health Board failed to respond to his complaint submitted to it in May 2024. It also failed to provide regular updates and failed to respond to several emails. The Ombudsman concluded that the Health Board had failed to respond to Mr X’s complaint and failed to provide regular updates in line with its complaint process. The Ombudsman said this caused uncertainty, frustration, and inconvenience to Mr X. 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, which should also include an apology and explanation for the delay. It should also offer a redress payment of £100 in recognition of the delay, lack of regular updates and need to approach the Ombudsman.

Mrs T complained that although her GP Practice (“the Practice”) accepted it did not make a referral to a Breast Clinic following her appointment on 9 September 2021, it had not considered the impact its error had caused on her treatment and prognosis when in May 2023 she was diagnosed with terminal Stage 4 breast cancer. We also considered what actions the Practice had taken in response to Mrs T’s complaint and whether these were sufficient to mitigate the chances of a similar incident happening in the future. The investigation found that a GP at the Practice failed to refer Mrs T twice to the Breast Clinic and these were significant service failures. The impact of these failures were that Mrs T’s diagnosis and treatment were delayed and it was more likely than not that an earlier diagnosis would have resulted in a better prognosis and a higher chance of a cure. The investigation also found that whilst the Practice had taken strong, robust action in response to Mrs T’s complaint, there were some further actions it could take to mitigate the chances of such an instance happening again. Mrs T’s complaint was upheld. The Ombudsman recommended that the Practice within 1 month: • Apologise to Mrs T. • Make a financial redress payment of £2,500 to reflect the significant services failures. • Ensure the case is discussed with the GP in question at their next appraisal. • Share guidance on safety netting with all its clinical staff. The Practice agreed to the Ombudsman’s recommendations.

Ms D complained about the care and treatment provided to her grandmother, Mrs F. Specifically, the investigation considered whether, between June 2021 and June 2022, Mrs F’s GP Practice failed to take appropriate action which would have resulted in an earlier diagnosis of her bladder cancer. My investigation found that Mrs F had ongoing urinary symptoms and a presence of blood in her urine without infection, which should have resulted in an urgent suspected cancer referral in July 2021. There were a number of missed opportunities to make this referral, and it was not made until May 2022. This was a significant service failing. I am saddened to conclude that had an urgent referral been made for Mrs F at an earlier stage, on balance, it is likely that the bladder cancer would have been diagnosed and treated sooner. Whilst I cannot be certain that this would have prevented Mrs F’s death, on balance, it is likely she would have survived longer. This is a grave injustice, not just to Mrs F, but as an enduring source of distress for Ms D and her family. I recommend that the Practice, within 1 month of this report: a) Provides Ms D with a fulsome apology for the failings identified in this report. The apology should make reference to the clinical failings, the impact of these on Mrs F’s outcome and the impact on Ms D and her family. b) Provides my office with confirmation that the new alert system for follow-up of patients with persistent blood in their urine is in use. I recommend that the Practice, within 2 months of this report: c) Reviews this case, along with its original significant event analysis, and the opportunity for earlier suspected cancer referral in line with NICE guidelines, to identify any points of learning which can be applied in future care and when dealing with complaints. d) Provides relevant clinicians with training on NICE guidelines for urinary tract infections in adults and bladder cancer diagnosis and management.

Mr X complained that Aneurin Bevan University Health Board had failed to respond to the complaint he submitted in April 2024. The Ombudsman decided that there had been a significant delay by the Health Board to provide Mr X with a response. She said this had caused frustration and uncertainty for Mr X. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to provide Mr X with a written apology, £150 redress in recognition of the delays and to issue a complaint response within 4 weeks.

Ms A complained because she was unhappy that Aneurin Bevan University Health Board could not secure suitable replacement transport following a provider’s withdrawal of service, resulting in her disabled son not being able to attend day services since April 2024. The Ombudsman found that the Health Board had originally secured the lease of a vehicle on a rolling monthly basis, but the vehicle was no longer suitable after Ms A’s son had a motorised wheelchair. Transport was suspended in April 2024 and the provider subsequently withdrew its services. Despite attempts to source a replacement provider the Health Board had not secured suitable transport. Therefore, Ms A’s son was suffering an injustice through no fault of his own. The Ombudsman sought and gained the Health Board’s agreement to apologise to Ms A for the delay, to provide an interim transport solution whilst long-term options are considered and to provide Ms A with an update on interim transport, within 1 month.

Mrs X complained that Anuerin Bevan Health Board failed to identify the cause of her debilitating back pain following several scans. Mrs X said she had to pay privately to establish that the Health Board had overlooked a herniated disc in her spine. The Ombudsman concluded that the Health Board had failed to provide a formal complaint response to address Mrs X’s concerns regarding the interpretation and accuracy of the MRI scan results. The Ombudsman said this caused uncertainty, frustration, and inconvenience to Mrs X. 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 to address the above concerns, and to offer an apology and explanation for the delayed response within 6 weeks.

Ms X complained that Aneurin Bevan University Health Board failed to respond to the complaint Ms X submitted in May 2024 regarding the sudden passing of her partner. Ms X further complained that both her and her advocate needed to chase the Health Board to obtain any updates, and Ms X felt the level of communication was poor. The Ombudsman concluded that the Health Board had failed to respond to Ms X’s complaint in line with its complaint process. The Ombudsman said this caused uncertainty, frustration, and inconvenience to Ms X. 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, which should also include an apology and explanation for the delay and lack of regular updates. A redress payment of £100 should also be offered to Ms X in recognition of the time and trouble expended having to chase for updates and for the need to approach the Ombudsman (within 3 weeks).

Mrs X complained that Aneurin Bevan University Health Board failed to respond to his complaint submitted 6 months ago regarding excessive waiting times for his mother’s elective orthopaedic surgery for total hip replacement. The Ombudsman concluded that the Health Board had failed to respond to Mrs X’s complaint in line with its complaint process. The Ombudsman said this caused uncertainty, frustration, and inconvenience to Mrs X. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to issue its formal complaint response, which should include an update in respect of the status of the wait for elective orthopaedic surgery. The response should also include an apology for the delay and lack of regular updates.

Mrs X complained that Aneurin Bevan University Health Board had failed to provide her with a response, which she had been waiting for over a year to receive. The Ombudsman found that the Health Board had responded to Mrs X’s first complaint from September 2023. However, she was subsequently asked to submit a second complaint in May 2024, and the Health Board had failed to issue a response to the second complaint. She said that this caused uncertainty and frustration to Mrs X. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to issue a complaint response within 2 weeks.

Mr A complained about the care and treatment provided to his late mother by Aneurin Bevan University Health Board (“the Health Board”). Specifically, regarding the appropriateness of the hospital discharge and his mother’s mobility assessments. Mr A also complained that the Health Board’s complaint responses did not address his questions. The Ombudsman was satisfied that the Health Board had already provided a reasonable response to his complaint but noted Mr A’s comment that he had not received copies of his mother’s mobility assessments. During a discussion with the Health Board, the Ombudsman was informed that it had no record of a request from Mr A asking for records, so it was unable to determine who he approached for the mobility assessments. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to consider a Subject Access Request which Mr A could formally submit to request his mother’s mobility assessments, if he wished to do so.

Miss S complained that Aneurin Bevan University Health Board failed to respond to her complaint, concerning the withdrawl of her care and treatment and arguing with her in front of patients, which was made in April 2024. The Ombudsman found that the Health Board failed to write to Miss S during its investigation to keep her updated with its investigation. This caused frustration and uncertainty for Miss S. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to write to Miss S, within two weeks, to apologise for failing to keep her updated and offer £100 for the inconvenience.

Mrs A complained that following registration, the Practice did not take appropriate steps to obtain her clinical records. Mrs A said that the Practice failed to follow up a referral to Mental Health Services and that it did not take account of information provided on the Practice’s appointment request system. Mrs A said that the Practice failed to adequately investigate and respond to her complaint. The investigation found no evidence of maladministration or service failure in relation to the clinical records. When Mrs A raised concerns about her referral to Mental Health Services, the Practice appropriately followed up the matter with the service. In response to Mrs A’s concerns about its appointment system, the Practice apologised for contacting her at times when she was not available and it took steps to identify how its system could be improved. The Ombudsman found that the Practice had considered Mrs A’s complaint, and provided an appropriate, albeit somewhat brief, response. The Ombudsman did not uphold the complaint.