PSOW Individual Decisions

Mr X complained that Aneurin Bevan University Health Board had failed to respond to his complaint, raised in December 2023. Mr X also complained about the lack of regular updates and the inconvenience of having to pursue updates from the Health Board. The Ombudsman concluded that the Health Board had failed to respond to the complaint in line with regulations and it failed to regularly update the complainant. She said this had caused uncertainty, frustration and inconvenience to Mr X. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to apologise for the delay and inconvenience caused and to issue its complaint response within 4 weeks.

Ms C complained about the standard of care provided to her grandfather, Mr D, in relation to identifying and treating his infection. Her complaint was about District Nursing care and inpatient hospital care at Ysbyty Ystrad Fawr. The Ombudsman found no evidence that Mr D should have been referred to hospital by District Nursing Staff; however, the District Nursing care records provided to the Ombudsman were wholly inadequate in relation to Mr D’s catheter care. The Health Board had also failed to respond to this aspect of Ms C’s complaint in its formal response to her. The complaint about District Nursing care was therefore partly upheld. The Ombudsman did not uphold the complaint about hospital care as the antibiotic choice, and the changes made to Mr D’s antibiotic treatment, were in line with clinical guidelines. The Ombudsman recommended that the Health Board should: • Apologise to Ms C for shortcomings identified • Review its systems for recording District Nursing care to ensure that its recording systems are adequate to maintain safe and professional care, and in line with current clinical practice • Undertake an audit of the current standard of community nursing recording.

Mrs A complained about hospital treatment provided by Aneurin Bevan University Health Board to her father, Mr B, between February and April 2020. The Ombudsman’s investigation considered the following questions: a) Were appropriate infection control measures put in place to protect Mr B from contracting COVID-19? b) Was the decision to discharge Mr B from Royal Gwent Hospital (“the Hospital”) appropriate? c) Was the Health Board’s Nosocomial (hospital-acquired) COVID-19 Review carried out appropriately? The investigation found that the infection prevention and control (“IP&C”) measures in place prior to Mr B contracting COVID-19 were in keeping with expected practice and relevant guidance. This complaint was not upheld. The investigation found that the decision to discharge Mr B from the Hospital was not appropriate because there had been a failure to carry out a full assessment of his confusion levels. This complaint was upheld. Finally, the investigation found that the Health Board’s Nosocomial Review had been carried out to a reasonable standard. This complaint was not upheld. The Health Board agreed to the Ombudsman’s recommendation that it should apologise to Mrs A for failing to carry out an appropriate assessment of Mr B’s confusion levels. It also agreed to remind relevant medical staff at the Hospital of the importance of ensuring that patients showing signs of delirium are appropriately assessed prior to discharge.

Mr B complained that Aneurin Bevan University Health Board had failed to respond to his complaint about delays in his wife’s orthopaedic treatment which he made to it in October 2023. The Ombudsman found that, although the Health Board had provided regular updates to the complainant, it had failed to provide the complaint response more than 6 months after the complaint had been received by it. The Ombudsman said this caused frustration to Mr B and decided to settle the complaint without a formal investigation. The Ombudsman sought and gained the Health Board’s agreement to apologise for the delay, explain the reasons for it, and to issue its complaint response within 4 weeks.

Mrs A complained that she was unhappy with the care and treatment provided to her late mother-in-law by Aneurin Bevan University Health Board (“the Health Board”). Mrs A was dissatisfied with the Health Board’s complaint handling and response. The Ombudsman decided that the Health Board failed to investigate some of Mrs A’s concerns, because it did not confirm her complaint in writing. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to apologise to Mrs A, confirm her outstanding concerns in writing, and agree to commence an investigation in line with Putting Things Right regulations, within 15 working days.

Miss A complained about the care and treatment provided to her late brother, Mr B, by a GP Practice in the area of Aneurin Bevan University Health Board (“the Practice”). Miss A complained specifically that between 26 January and 13 March 2023 the Practice failed to provide appropriate care and treatment to Mr B and undertake appropriate investigations into his reported breathlessness. The investigation found that the care and treatment provided to Mr B by the Practice fell below expected standards. This is because, although an appropriate history was taken, the examination recorded on 26 January 2023 was inadequate and the follow-up or safety-netting plan was absent. The Practice failed to take appropriate action to investigate Mr B’s breathlessness as it did not make a follow-up plan to review, investigate or refer Mr B. The Ombudsman therefore upheld the complaints. The Ombudsman recommended that the Practice should apologise to Miss A for the failings identified and provide evidence that it has reflected on the care provided and undertaken relevant learning.

Mrs N complained that Aneurin Bevan University Health Board (“the Health Board”) failed to provide her with appropriate care while she received blood transfusions and discharged her inappropriately after the transfusions were complete. Mrs N also complained that the GP Practice failed to appropriately assess and treat Mrs N’s symptoms in her left foot and leg when she was seen 4 days after her discharge. The Ombudsman found that Mrs N was appropriately monitored during the blood transfusions and that it was appropriate not to prescribe treatment to prevent blood clots. She was appropriately monitored during the transfusions and her discharge and the plan for follow-up care were clinically appropriate. There was no clinical reason for Mrs N to stay in hospital once her blood transfusions were complete. These elements of the complaint were not upheld, although the Ombudsman invited the Health Board to consider how it could ensure that patients are informed of appropriate self-care following blood transfusions, and the warning signs of a negative reaction. The Ombudsman found that the documented assessment of Mrs N’s foot and leg when she was seen at the GP Practice was inadequate. Relevant clinical findings were omitted and indications of the severity of her reduced blood flow were misinterpreted. Mrs N should have been referred urgently to the Vascular Team but, as a result of these failures, her referral and assessment by that team was delayed by at least 24 hours. This delay did not materially impact the clinical treatment Mrs N received, which ultimately required her leg to be amputated. However, if the GP had considered all the relevant factors and appropriately referred Mrs N for an immediate review by the Vascular Team, this could have reassured her that her concerns were taken seriously and that everything possible was done, even if this would not have saved her leg. This element of the complaint was therefore upheld. The GP Practice agreed to apologise to Mrs

Mrs N complained that Aneurin Bevan University Health Board (“the Health Board”) failed to provide her with appropriate care while she received blood transfusions and discharged her inappropriately after the transfusions were complete. Mrs N also complained that the GP Practice failed to appropriately assess and treat Mrs N’s symptoms in her left foot and leg when she was seen 4 days after her discharge. The Ombudsman found that Mrs N was appropriately monitored during the blood transfusions and that it was appropriate not to prescribe treatment to prevent blood clots. She was appropriately monitored during the transfusions and her discharge and the plan for follow-up care were clinically appropriate. There was no clinical reason for Mrs N to stay in hospital once her blood transfusions were complete. These elements of the complaint were not upheld, although the Ombudsman invited the Health Board to consider how it could ensure that patients are informed of appropriate self-care following blood transfusions, and the warning signs of a negative reaction. The Ombudsman found that the documented assessment of Mrs N’s foot and leg when she was seen at the GP Practice was inadequate. Relevant clinical findings were omitted and indications of the severity of her reduced blood flow were misinterpreted. Mrs N should have been referred urgently to the Vascular Team but, as a result of these failures, her referral and assessment by that team was delayed by at least 24 hours. This delay did not materially impact the clinical treatment Mrs N received, which ultimately required her leg to be amputated. However, if the GP had considered all the relevant factors and appropriately referred Mrs N for an immediate review by the Vascular Team, this could have reassured her that her concerns were taken seriously and that everything possible was done, even if this would not have saved her leg. This element of the complaint was therefore upheld. The GP Practice agreed to apologise to Mrs

Mrs R complained about the care provided to her husband, Mr R, by Aneurin Bevan University Health Board during his admission to a psychiatric hospital ward (“the first hospital”) between 3 February and 27 June 2022. Mrs R also complained about the management of Mr R’s risk of blood clots and discharge after a brief admission to a general hospital (“the second hospital”) between 20 and 22 June 2022. The Ombudsman found that Mr R was prescribed and given appropriate medication during his admission to the first hospital, which was in line with guidelines for the treatment of his Alzheimer’s Disease. She also found that Mr R’s mental and physical health was reviewed regularly both in-person and at weekly meetings, and his Care and Treatment Plan and medication were adjusted as necessary. Nursing staff appropriately alerted doctors to issues when necessary. These complaints were not upheld. The Ombudsman found that Mr R’s fluid intake was, generally, adequate. However, more should have been done to encourage him to drink during a heatwave and so she upheld this element of the complaint to this limited extent. The Ombudsman found that medication to prevent blood clots was appropriately withheld when Mr R was initially transferred to the second hospital. This was because Mr R had fallen and might have had internal bleeding. The decision not to scan Mr R’s head (to confirm or rule out any internal bleeding) until the day after his transfer was not ideal, but was of a clinically acceptable standard of care. However, clot-preventing medication should have been prescribed once the risk of bleeding had been excluded and so, to this extent, this element of the complaint was upheld. The Ombudsman found that Mr R’s discharge from the second hospital (back to the first hospital) was safe and appropriate. This element of the complaint was not upheld. The Health Board confirmed that it had already introduced a number of audits to measure and monitor quality of care through a Health B

Mrs A complained that the sedative medication given to her late husband, Mr A, on 8 September 2021 during his inpatient admission to Grange University Hospital was not appropriate. Sadly, Mr A, who had chronic health conditions, suffered a cardiac arrest during this admission and died the next day. Mrs A also said that there was inadequate communication with the family about her husband’s deteriorating condition. She also complained about the Health Board’s complaint handling and the inadequacies in its complaint response of 4 April 2023. In terms of the sedation medication, the Ombudsman said that clinicians were entitled to prescribe the sedative haloperidol, to treat Mr A’s acute confusion even though prescribing guidance meant that there were contraindications due to Mr A’s presenting heart condition. However, the Ombudsman was critical that the reason for not following prescribing guidance was not documented and that there was no management plan documented around the prescribing and administering of haloperidol. Whilst the Ombudsman could not say definitively what role, if any, haloperidol played in Mr A’s subsequent cardiac arrest and death, the Ombudsman concluded that the injustice for Mrs A was that she would have to live with the uncertainty of not knowing whether her husband’s outcome might have been different if haloperidol had not been administered. This part of Mrs A’s complaint was upheld. The Ombudsman did not find inadequacies when it came to communication with the family and did not uphold this part of Mrs A’s complaint. The Ombudsman was critical about the Health Board’s complaint handling and complaint response around Mr A’s sedation medication. The Ombudsman’s found that the family had not been told about a medication error that had led to Mr A being given too much of another sedative nor had the fact that Mr A had been prescribed and administered haloperidol been mentioned. The Ombudsman concluded that Mrs A had been caused an injustice, as the

Ms A complained that she was unhappy with the Practice’s response to her complaint about accessing appointments over the past 12 months. The Ombudsman decided that the Practice’s response did not explain what it found as a result of its investigation into Ms A’s concerns. It did not confirm if any learning was identified or if any changes could be made. No information was provided about how to escalate the complaint to the Ombudsman. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Practice’s agreement to reconsider Ms A’s complaint, explain what it found in its investigation and any learning points identified. The Practice also agreed to review the information it provides to complainants about their rights to escalate their complaints.

Mrs V complained that Aneurin Bevan University Health Board failed to respond to the complaint she made to it in January 2024. The Ombudsman found that the Health Board had failed to notify Mrs V that there was a delay in responding to her complaint and had not provided a reason why. The Ombudsman said that this caused frustration and uncertainty for Mrs V. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to apologise to Mrs V and pay her redress of £50 in recognition of the time and trouble she had spent complaining to the Ombudsman. The Health Board also agreed to provide Mrs V with a complaint response within 4 weeks.

Mrs A complained about the care and treatment provided by a GP Practice to her late mother, Mrs B, in July and August 2022. The Ombudsman investigated whether antibiotics should have been prescribed at or following a home visit on 25 July 2022, whether home visits should have been carried out on 26 July and 11 August 2022 and whether anticipatory (end-of-life) medications should have been prescribed sooner than they were. The investigation found that the decision not to prescribe antibiotics at or following the home visit on 25 July 2022 was appropriate. This is because there was no clinical indication that Mrs B’s deterioration at that time was due to a urinary tract infection. The investigation further found that the decisions not to carry out home visits on 26 July or 11 August were appropriate. The investigation also found the fact that anticipatory medications were not prescribed until 12 August was within the range of appropriate clinical practice. The Ombudsman did not uphold the complaints.

Mr A complained that Aneurin Bevan University Health Board had failed to respond to the complaint made to it in June 2023 or proactively provide updates. The Ombudsman found that the Health Board had issued several holding letters to Mr A, some after being prompted by his advocate. The Health Board had failed to respond to the complaint or to tell Mr A when its response would be issued. The Ombudsman said this caused frustration to Mr A and decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to apologise for the delay and explain the reasons for it and to issue its complaint response within 4 weeks.

Miss D complained that Aneurin Bevan University Health Board failed to issue a response to her complaint, which she made to it in July 2023. The Ombudsman found that whilst the Health Board had initially dealt with Miss D’s concerns informally, it subsequently failed to log her concerns as a formal complaint when she remained dissatisfied. She said that this caused frustration and uncertainty to Miss D. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to write to Miss D with an apology for its failure to raise a formal complaint and issue a complaint response within 4 weeks.

Ms X complained that Aneurin Bevan University Health Board had failed to respond to her complaint, or provide regular updates, in respect of her complaint submitted to it 6 months ago. The Ombudsman decided that the Health Board had failed to provide Ms X with a response, and regular updates, which caused frustration and uncertainty to Ms X and led her to contact the Ombudsman. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to issue its complaint response (within 2 weeks), which should also include an explanation and apology for the delay, plus a redress payment of £100.

Mr X complained that Aneurin Bevan University Health Board had failed to respond to the complaint he made to it in August 2023 about the care and treatment provided to his late mother, Mrs Y. Mr X said that the Health Board had not updated him on its investigation. The Ombudsman found that the Health Board had failed to provide a complaint response or keep Mr X appropriately updated during its investigation. She said this caused frustration for Mr X and decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to apologise to Mr X for the delay and failure to update him, explain the reasons for those failures to Mr X, offer him a £150 redress payment, and to issue the complaint response within 6 weeks.

Mrs D complained that Aneurin Bevan University Health Board failed to provide a response to her complaint, which she 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 Mrs D. She said that this caused frustration and uncertainty to Mrs D. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to provide an apology for the identified failures, offer £150 redress to Mrs D in recognition of her time and trouble in making her complaint to the Ombudsman and issue a complaint response within 2 weeks.

Ms D complained that Aneurin Bevan University Health Board failed to provide a response to her complaint, which she made to it in September 2023. The Ombudsman found that whilst the Health Board had provided regular and meaningful updates to Ms D, it had failed to issue a complaint response. She said this caused frustration to Ms D. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to write to Ms D with an apology for the delay and to issue a complaint response within 4 weeks.

Mr A complained about the care and treatment provided to him by Aneurin Bevan University Health Board. The investigation considered whether the Health Board investigated his symptoms properly during consultations in June and October 2021 and whether diagnosis earlier than August 2022 would have resulted in earlier treatment of his oropharyngeal cancer (a type of head and neck cancer). The investigation found that that the consultations of 14 June and 5 October were of a clinically acceptable standard. There was no evidence to suggest that there were missed opportunities to refer Mr A for further investigation during these consultations. The Ombudsman did not uphold the complaint. In respect of whether an earlier diagnosis would have resulted in earlier treatment of Mr A’s oropharyngeal cancer, the investigation found that a later consultation with Mr A on 31 May 2022 was clinically appropriate, but the requested procedures should have been carried out sooner. This would probably have resulted in Mr A’s treatment commencing earlier. Whilst it was likely that Mr A’s treatment plan would have been the same had he been diagnosed more promptly, Mr A suffered avoidable mental distress because of the delay, which was an injustice to him. The Ombudsman upheld Mr A’s complaint. The Health Board agreed to provide Mr A with a meaningful apology for the failings identified and to make a redress payment to him of £500. Additionally, it agreed to provide a reminder to clinicians to consider expediting biopsy procedures where there is evidence of a new mass and risk of malignancy, and to remind clinicians about the policy for patients presenting with a tonsil mass to arrange all imaging scans at the first appointment.

Mrs K complained about the care provided to her father, Mr C, by Aneurin Bevan University Health Board. She said that a doctor should have attended to him during a 10-hour period overnight, shortly before his death. The Ombudsman found that nursing staff repeatedly requested a medical review of Mr C, which should have prompted the On-Call Team to attend. The care provided and the telephone advice given were in line with appropriate clinical standards, but the lack of direct medical review left Mrs K feeling like she and her father had been abandoned at the end of Mr C’s life, which had a lasting effect on her in her grief and was a significant injustice. Additionally, the failure of the On-Call Team to attend to review Mr C was not escalated by staff in line with the Health Board’s Deteriorating Patient Policy. This failure to escalate meant that consideration and oversight of why the On-call team had been unable to attend did not take place. The complaint was upheld. The Health Board agreed to apologise to Mrs K, to remind relevant staff of the importance of completing necessary documentation and of the escalation procedure from the Deteriorating Patient Policy. It also agreed to demonstrate that there is a robust process in place to identify the causes of non-attendance and take action to mitigate the risks of those causes reoccurring.

Ms E complained that Aneurin Bevan University Health Board failed to accept her complaint about the care and treatment provided to her late sister due to it being considered out of time. The Ombudsman found that the Health Board had incorrectly refused to accept Ms E’s complaint. She said that this caused frustration to Ms E. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to provide an apology and explanation to Ms E for the identified failures and offer £50 redress in recognition of her time and trouble in making her complaint to the Ombudsman within 2 weeks. It was further agreed to issue a complaint response within 12 weeks.

Ms D complained that Aneurin Bevan University Health Board failed to respond to the further concerns she raised with it in October 2023. The Ombudsman decided that there had been a delay by the Health Board to respond to Ms D’s further concerns and this had caused inconvenience and frustration for her. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to apologise to Ms D, pay her redress of £150 in recognition of the time and trouble spent complaining to the Ombudsman and to issue the response within 4 weeks.

Miss O complained about the overall care and treatment her mother, Mrs N, received following her admission to the Grange Hospital on 10 August 2021. Miss O was especially unhappy at the staff’s lack of knowledge about her mother’s Good’s syndrome, the lack of communication between staff and her family about her mother’s condition/prospects, the decision to withdraw treatment when her mother was not dying and the lack of palliative care involvement at the end of her mother’s life. The Ombudsman’s investigation found that whilst Good’s syndrome is rare, clinicians looking after Mrs N had a basic knowledge of the condition and sought advice from a more specialist team at the appropriate time. The Ombudsman also found that communication with Mrs N’s family was, overall, appropriate and her condition/prospects were communicated to her family on more than one occasion. The Ombudsman also found that treatment was withdrawn at the most appropriate time and Mrs N received care from the Palliative Care Team at the correct time. The Ombudsman did not uphold Miss O’s complaint.

Mrs V complained that Aneurin Bevan University Health Board failed to issue a response to her complaint, which she made to it in May 2023, regarding the care and treatment provided to her late husband. The Ombudsman found that the Health Board had failed to issue a complaint response. She said this caused frustration and uncertainty to Mrs V. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to apologise and provide an explanation to Mrs V for the delay, issue a complaint response, and offer a redress payment of £75 in recognition of her time and trouble in making a complaint to the Ombudsman.