PSOW Individual Decisions

Mr B was diagnosed with a non cancerous brain tumour (a schwannoma). He complained about the lack of clarity around the management of his brain tumour and the impact it had had on him. The Health Board agreed as part of an early resolution settlement (ER) to write to Mr B and explain in plain English his medical condition and the effectiveness of his radiotherapy treatment. As part of the ER the Health Board would also explain why it considered it appropriate for Mr B’s specialist monitoring scans to now be carried out every 2 years (previously it had been annually). In addition, the Health Board agreed it would let Mr B know who would be responsible for his care going forward and it would apologise to him for the confusion around his care.

Ms B complained that Aneurin Bevan University Health Board had treated her unfairly and that this caused her distress. The Ombudsman found that the Health Board had failed to provide a 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 provide Ms B with a complaint response within 5 weeks which should also include an explanation and explain why a formal response was not provided when the complaint was raised.

Mr X complained that the Surgery failed to fully respond to his complaint regarding concerns with the issuance of incorrect stoma prescriptions for his father. The Ombudsman concluded that whilst the Surgery had responded to Mr X’s complaint, it had failed to respond to all aspects of the complaint. 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 Surgery’s agreement to apologise for the oversight, delay and inconvenience caused and to issue a further complaint response within 3 weeks.

Ms X complained that Aneurin Bevan University Health Board had failed to respond to her complaint submitted to it in April 2024 in respect of her son’s care. The Ombudsman concluded that the Health Board had failed to respond to the complaint in line with its internal complaint process, and it also failed to provide regular meaningful updates to Ms X. 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 and apologise for the delay and lack of regular meaningful updates, within 3 weeks.

Mrs A complained that the Practice failed to identify the seriousness of her husband’s symptoms or refer him to hospital, when he attended on 4 separate occasions over a 16-day period. Mr A had to have his leg amputated 8 days after he was last seen at the Practice. The investigation found that Mr A’s care and treatment over the 16-day period was appropriate. From the information available, Mr A’s symptoms and signs changed after he was last seen at the Practice, and warranted urgent medical attention. The Ombudsman did not uphold the complaint.

Ms A complained about the circumstances leading up to the stillbirth of her daughter, B, whilst under the care of Aneurin Bevan University Health Board (“the Health Board”). Whilst the Health Board have acknowledged failings in care, identified these caused harm and accepted this amounts to a qualifying liability, the Ombudsman recognised that Ms A had outstanding concerns. The Ombudsman sought and gained the Health Board’s agreement to within 1 month, apologise to Ms A for the time taken to conclude the complaints/redress process, apologise for not providing an answer to her concerns about B’s heart rate and apologise for any discrepancies between the initial hospital review in 2022 and the final response in 2024. The Health Board also agreed to provide explanations to the relevant outstanding concerns.

Mrs B complained about the care and treatment her late mother, Mrs A, received from the Health Board when she was admitted to the Grange University Hospital (“the Hospital”) between 28 January and 3 February 2023. Specifically, the investigation considered whether the provision of intravenous (administered into a vein) antibiotics to Mrs A on 30 January was appropriate and timely. The investigation found that Mrs A did not receive reasonable care and treatment from the Health Board because although the provision of intravenous antibiotics to Mrs A on 30 January 2023 was appropriate, it was not timely as they should have been prescribed more rapidly on 29 January. However, the investigation established that Mrs A did not suffer injustice as a result of the failure because it was unlikely that provision of intravenous antibiotics any earlier would have affected her sad outcome. Mrs B’s complaint was not upheld.

Mrs A’s complaint centered around 3 areas: a) whether her husband’s April 2022 transurethral resection of bladder tumour (TURBT) surgical procedure to remove a bladder tumour at the Royal Gwent Hospital (“the Hospital”) was carried out appropriately b) whether he was appropriately discharged and finally c) whether her husband’s later attendance at the Hospital in May of that year was appropriately managed. The Ombudsman found that the TURBT had been carried out appropriately and that Mr A’s post operative care, treatment and management, including for his May attendance was also reasonable and appropriate. Mrs A’s complaints were not upheld.

Mr J complained that he has not received a reply from the Orthopaedic department to his complaint which was raised on 21 May 2023. The Ombudsman found that Mr J was told on 24 April 2024 that a draft response was completed but needed approval. He was told the same on 12 July and 18 September. On 17 October the Health Board told the Ombudsman that the response was undergoing scrutiny by the senior team. The Ombudsman decided to settle the complaint without an investigation as the Health Board agreed to issue Mr J with an aplogy for the delay in responding to his complaint and issue the final response within 20 working days.

The investigation considered Mr A’s complaint regarding Aneurin Bevan University Health Board’s (“the Health Board”) consideration of his claim for retrospective NHS Continuing Healthcare (“CHC”) funding, in respect of the late Mrs B which, he said, was flawed. In particular, Mr A said that the Independent Review Panel (“the IRP”) failed to consider, or refer to, relevant evidence and the family’s submissions, and failed to properly apply the correct eligibility tests. The investigation found that the composition, arrangement and actions of the IRP were in line with the Continuing NHS Health Care: The National Framework for Implementation in Wales. The IRP had access to, considered and deliberated the relevant evidence (which included the written evidence and oral submissions made by the family). The IRP also applied the correct eligibility tests when coming to its decision. The complaint was therefore not upheld.

Mrs X complained that Aneurin Bevan University Health Board failed to provide a complaint response to her complaint, which she made to it in November 2023. The Ombudsman found that, whilst the Health Board had been in regular contact with Mrs X, it had failed to issue a complaint response. The Ombudsman said that this caused frustration to Mrs X and decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to write to Mrs X with an apology and explanation for the delay and to issue its complaint response within 4 weeks.

Mr A complained that his discharge from hospital on 14 December 2023 was inappropriate. The investigation identified that Mr A was a complex patient who did not receive the multi-team input he needed prior to his discharge. The Health Board agreed to apologise to Mr A for its lapse in care. In addition, in order to prevent any similar future occurrences, the Health Board agreed that within 3 months it would put in place the following arrangements: • Prior to a step-down in a level of care, complex patients should have a multi-disciplinary meeting, with each specialty’s responsibilities clearly outlined in an easily visible shared care document. • Prior to discharge, complex patients should have a multi-disciplinary meeting, with each specialty providing their views in an easily visible shared document.

Mr A complained that a dental practice had not provided treatment for an issue with his front tooth. He said that he had made a complaint regarding this but had not received a response as the dental practice had closed and contact was unable to be made with the dentist that had treated him. The Ombudsman found that Bupa Dental Care could have investigated and responded to Mr A’s complaint, despite not being able to contact the dentist that treated him. Bupa Dental Care agreed to apologise to Mr A, offer him a payment of £100 to reflect the time and trouble taken for him to pursue his complaint and provide a full and final response to his complaint.

Mrs T complained about the standard of care and treatment provided to her mother, Mrs V, following her admission to hospital on 20 March 2022 in respect of her atrial fibrillation and a wrist fracture. The Ombudsman began an investigation, however, shortly afterwards, it became clear that Aneurin Bevan University Health Board (“the Health Board”) were still investigating Mrs T’s concerns. The Ombudsman therefore paused her investigation. Ultimately, the Health Board concluded that Mrs V had suffered personal injury arising from a breach of duty of care and Mrs V had suffered harm because of the breach. The Health Board offered Mrs T a significant financial sum and free, independent legal advice to consider its findings. As Mrs T now had a legal remedy available to her, the Ombudsman could not continue her investigation and Mrs T’s complaint was discontinued.

Ms A said that Aneurin Bevan University Health Board failed to provide a response to her complaint, which she made to it in January 2024. The Ombudsman found that the Health Board had not provided regular and meaningful updates and had not issued a complaint response. She said that this caused frustration and uncertainty to Ms A. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to write to Ms A with an apology for the identified failures, offer £150 redress in recognition of Ms A’s time and trouble in making her complaint to the Ombudsman and to issue a complaint response within 6 weeks.

Mrs C complained about care provided to her mother, Mrs D, by the Health Board. The Ombudsman considered whether Mrs D’s discharge from hospital on 12 February 2021, including planned aftercare and follow-up, was clinically appropriate. The Ombudsman found that at the time Mrs D was discharged, her white blood cell count was still raised. However, her observations were stable and there were no acute changes to her condition. It was appropriate for her to have been discharged; she was to continue oral antibiotics and arrangements were made for her to have further outpatient investigations and blood tests. There was no requirement for the Health Board to have arranged any package of care for her, as she was self-caring in hospital and there was no reason to believe she would not continue to be so. The Ombudsman found that it was appropriate that the medication Mrs D was receiving while she was in hospital, to reduce the risk of blood clots, was stopped before she was discharged from hospital. However, there was no evidence that Mrs D was advised of the importance of good hydration and leg exercises, as recommended by guidance. There was no way of knowing whether hydration and exercises alone would have prevented Mrs D suffering a pulmonary embolism (“PE” – a serious condition caused by a blood clot in the lungs). However, the fact this advice was not given to her meant she lost the opportunity to reduce the risk of this occurring, and this was an injustice to her. The Ombudsman therefore upheld the complaint to this extent. The Health Board agreed to the Ombudsman’s recommendations to apologise to Mrs C, to pay her financial redress of £500, and to remind relevant clinicians to provide appropriate information prior to discharging patients at risk of PE.

Ms X complained that an agency nurse for Aneurin Bevan University Health Board administered her elderly mother with incorrect medication whilst she was an inpatient at the Royal Gwent Hospital. The Ombudsman decided that whilst the Health Board had responded to Ms X’s complaint, it failed to explain what learning and improvements have happened since the complaint. The Ombudsman said this caused uncertainty, frustration, and inconvenience to Ms X. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to issue a further response to Ms X within one week which provides clarification on the learning and improvements that have been made as a result of the complaint.

Ms L said that Aneurin Bevan University Health Board failed to provide a response to her mother’s (Ms S) complaint, about the care and treatment provided to her late husband, which she made to it in November 2023. The Ombudsman found that the Health Board had failed to issue a complaint response and had not provided regular and meaningful updates to Ms S. She said that this caused frustration and uncertainty to Ms S. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to write to Ms S with an apology for the identified failures and to issue a complaint response within 6 weeks.

Mr T said that Aneurin Bevan University Health Board failed to provide a response to his complaint about the care and treatment provided to his late father, which he made to it in May 2023. The Ombudsman found that the Health Board had failed to issue a complaint response and had not provided regular and meaningful updates to Mr T. She said that this caused frustration and uncertainty to Mr T. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to write to Mr T with an apology for the identified failures, offer to pay £150 redress in recognition of Mr T’s time and trouble in making his complaint to the Ombudsman and to issue a complaint response within 4 weeks.

Mrs B made a complaint to Aneurin Bevan University Health Board on 24 April 2021 about the care she received when she became unwell after having a COVID-19 vaccination. Mrs B complained to the Ombudsman that she had not received a final response to her complaint and had not received any updates since August 2023. Assessment of Mrs B’s complaint identified that her complaint had not been resolved. Following legal advice in March 2023, additional information that was identified as being required was still outstanding. The Health Board agreed to, within 4 weeks, issue Mrs B with an apology and explanation for the length of time that it has taken to address her complaint. It would also include an apology for not keeping her updated during this process. The Health Board also agreed to, within 6 weeks, issue Mrs B with a final response to her complaint.

Mr A complained that the Health Board had not responded to additional queries he raised following the Health Board’s reply to his formal complaint. The investigation found that over 3 months had passed since Mr A raised his additional queries, but the Health Board had not responded. It was therefore not possible to say whether the Health Board agreed with or rejected Mr A’s concerns. In order to resolve Mr A’s complaint, the Health Board agreed to arrange for a staff member to contact Mr A directly and to issue a written response to his queries within 4 weeks. The Ombudsman considered that the action the Council had agreed to take was reasonable and the matter was settled. Mr A would be able to return to the Ombudsman with his complaint in due course if he was not satisfied with the Health Board’s final response.

Ms K complained that Aneurin Bevan University Health Board failed to provide a complaint response to her complaint, which she made to it in December 2023. The Ombudsman found that whilst the Health Board had facilitated a face to face meeting and provided updates, it had failed to issue a complaint response. The Ombudsman said that this caused frustration to Ms K and decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to write to Ms K with an apology and explanation for the delay and to issue its complaint response within 2 weeks.

Mrs X complained that Aneurin Bevan University Health Board had failed to provide adequate care to her son during pregnancy and post birth. Mrs X complained that her son’s health conditions could have been diagnosed sooner had she been offered a further 20-week scan. The Ombudsman found that Mrs X had raised a complaint with the Health Board, however it had failed to respond to the complaint or provide Mrs X with any updates after October 2023. The Ombudsman said this caused frustration and uncertainty to Mrs X. She decided to settle the complaint without an Investigation. The Ombudsman sought and gained the Health Board’s agreement to apologise to Mrs X for the lack of regular updates, provide an explanation for the delay in issuing a complaint response and offer to pay her £200 redress for her time and trouble in making the complaint to the Ombudsman. Furthermore, the Health Board agreed to issue a complaint response within 4 weeks.

Mr A complained about the GP Practice’s complaint response about his mother’s management and care in February 2024. Mr A also complained about a later period of care (in April ) that the GP Practice had not had an opportunity to consider. The Ombudsman exercised her discretion and decided to look into this aspect of Mr A’s complaint. As part of the settlement the GP Practice were asked to provide a written response to address the specific concerns that Mr A had raised about his mother’s management in the February; apologise to Mr A and his mother for the shortcomings in complaint handling and the distress that shortcomings in the second episode of care had caused them. Additionally, the Medical Practice was to reinforce at an appropriate forum to non-clinical staff appropriate clinical/non-clinical boundaries during patient interactions which would include situations where clinical input is required as well as review the April episode of care and identify areas for learning. Finally, if this is not already in place, the GP Practice should ensure that patient contact with non-clinical staff was appropriately recorded in the patient’s clinical records.

Mr A complained about the care of his wife by the Health Board before and after an endoscopy (a procedure to look inside the body with a small camera) in 2023. Mrs A fell following the procedure which had required the use of sedation. Mr A had written twice with concerns to the Health Board, in November 2023 and May 2024. He raised some new concerns in his May letter. The Health Board had replied to his first letter but not to the second. Some aspects of his complaints had therefore not been addressed. The Health Board agreed to reply fully to Mr A’s second letter within 8 weeks, and to apologise to him for not replying to that letter.