PSOW Individual Decisions

Mrs C complained about the care provided to her when she presented to the Grange Hospital on 24/25 June, and then on 28 June, with uncontrolled pain caused by a dislodged kidney stone. The investigation found that the standard of care provided to Mrs C on 24/25 June was appropriate. However, there was a failing in the Health Board’s record keeping on 28 June because there was no evidence that Mrs C’s pain was properly monitored or recorded whilst she was in hospital or at discharge. This meant that the Ombudsman was not fully able to determine Mrs C’s complaint about whether the plan for the management of her kidney stone was appropriate. The Ombudsman upheld this aspect of the complaint to that extent. The Ombudsman recommended that the Health Board should apologise to Mrs C for the identified failings, and review the details of this complaint with relevant clinical staff to ensure that pain is properly assessed and recorded in similar cases. The Health Board accepted the recommendations.

Mrs B complained about the care and treatment that her late husband, Mr B, received from the Health Board and the Trust in 2020. In relation to the Trust, Mrs B complained that the Consultant Oncologist did not offer Mr B chemotherapy treatment, did not clearly explain the reasons for that decision, and did not tell Mr B that he had advanced cancer and stage 3 chronic kidney disease. In relation to the Trust and the Health Board, Mrs B complained that further referrals to the Trust for consideration of chemotherapy were not made or acted on at a time when Mr B was well enough to benefit from the treatment. In relation to the Health Board, Mrs B complained that there was an unreasonable delay in investigating and treating Mr B’s deep vein thrombosis, investigating Mr B’s enlarged lymph node and carrying out a biopsy following a referral by his GP. Mrs B also complained that she was not allowed to visit her husband in hospital when he was at the end of his life and that there was a delay in the Health Board responding to the complaint, as well as failing to arrange a meeting to discuss the complaint findings. The Ombudsman concluded that it was the Consultant Oncologist’s responsibility to ensure Mr B understood his illnesses insofar as they related to the risks and benefits of chemotherapy in order to demonstrate that decisions were appropriately made. It was determined that the risks of chemotherapy were not proportionately weighed against the benefits and, although the outcome for Mr B may not have been any different, chemotherapy should have been offered. This was an injustice to him and this complaint against the Trust was upheld. The Ombudsman did not uphold the complaint against both the Trust and the Health Board, that further referrals for chemotherapy were not made or acted upon. Some delays were identified in timescales for appointments and investigations prior to the further referral to oncology on 21 September but this would not have made a difference to

Mrs A complained that Aneurin Bevan University Health Board has failed to issue a response to her complaint, which was originally made to it in January 2023 by her late husband. The Ombudsman found that the Health Board had failed to issue a complaint response and had not provided regular and meaningful updates. She said that this caused frustration and uncertainty to Mrs A. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to apologise to Mrs A for the lack of regular and meaningful updates, provide an explanation for the delay in issuing a complaint response and offer to pay £150 redress to Mrs a for her time and trouble in making her complaint to the Ombudsman within 4 weeks. Furthermore, the Health Board will provide Mrs A with monthly updates until its complaint response is issued.

Mrs B complained about the advice her husband Mr B received from an Advanced Nurse Practitioner (ANP) employed by the Out of Hours GP service, shortly before he was admitted to hospital and sadly died of neutropenic sepsis. Mrs B said that a home visit she requested should have been arranged for her husband in light of his leukaemia diagnosis and the symptoms he had been displaying earlier that day. The Ombudsman found that the ANP should have arranged for Mr B to have been visited by the district nurses or an Out of Hours GP to enable blood tests to have been carried out in light of his condition and his high risk of developing neutropenic sepsis, although she recognised that this was not an obvious or easy decision for the ANP to make in the circumstances. The Ombudsman upheld Mrs B’s complaint that the care and treatment provided to her husband was not clinically appropriate. The Health Board agreed to the Ombudsman’s recommendation to apologise to Mrs B within 1 month.

Mr X complained that Aneurin Bevan University Health Board had failed to respond to his complaint regarding the care and treatment of his late father, submitted to it in June 2023. The Ombudsman decided that there had been delays and oversights with the response, which she said 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 provide the complainant with an apology for the delay, a redress payment of £100 and to issue its complaint response within 2 weeks.

Mr L complained that Aneurin Bevan University Health Board failed to respond to his complaint about the care and treatment provided to his late mother, which he made to it in October 2023. The Ombudsman found that the Health Board had not issued a complaint response and had not provided regular and meaningful updates to Mr L. She said this caused frustration and uncertainty to Mr L. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to write to Mr L with an apology for the failure to provide regular and meaningful updates and to issue a complaint response within 4 weeks.

Ms L complained that Aneurin Bevan University Health Board had failed to respond to the complaint she had made to it in December 2022. The Ombudsman found that Ms L had initially complained in December 2022 and escalated her complaint further in May 2023. The Health Board had failed to respond or properly update Ms L. The Ombudsman said this caused frustration to Ms L and decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to apologise to Ms L for failing to respond or properly update her, to explain the reasons for the delay, to offer Ms L a £250 redress payment, and to issue its complaint response within 4 weeks.

Mr B complained about the service he received from a dental practice (“the Practice”) in the area of Aneurin Bevan University Health Board. He complained that the Practice did not have a complaints policy displayed or provide him with a copy. He said that they did not provide him with a copy of its policy regarding payments or its unreasonable behaviour policy. Mr B was also unhappy with the Practice’s response to his complaint and that it issued him with a formal warning following his complaint. The assessment of Mr B’s complaint identified that the Practice had apologised to him for the distress and inconvenience he experienced during his visit. The assessment also identified that Mr B was not reminded of the payment policy before his dental treatment was undertaken and that he did not receive a copy of its unreasonable behaviour and complaint policies. The Practice agreed to confirm to Mr B in writing that the formal warning has been removed from his record and supply him with a copy of its policy that includes payment terms, its unreasonable behaviour policy and its complaints policy. The Ombudsman considered this was a reasonable way to resolve Mr B’s complaint and it was closed on this basis.

Ms X complained that Aneurin Bevan University Health Board had failed to respond to the complaint made to it in July 2023. The Ombudsman found that the Health Board had directly updated the complainant during the investigation but had not issued its complaint response. The Ombudsman said this caused frustration for Ms X and decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to apologise to Ms X for the delay, explain the reasons for the delay, and to issue the complaint response within 6 weeks.

Mrs C complained about the care and management her late husband, Mr A, received from the GP Surgery (“the Surgery”) between May and November 2021. The Ombudsman investigated whether there were unacceptable delays in making appointments and telephone consultations for Mr A between May 2021 and 23 November 2021, and whether the quality of the assessment Mr A underwent on 10 August 2021 was appropriate and whether an alternative diagnosis of cancer should have been considered at that time. Mrs C also complained about the care and treatment Mr A received from Aneurin Bevan University Health Board (“the Health Board”). The Ombudsman investigated whether it was appropriate to downgrade Mr A’s “urgent suspected cancer” (“USC”) referral made by the Surgery on 8 September 2021 to “urgent”, and whether there was an unacceptable delay in the Health Board’s response to Mrs C’s complaint and to her attempts to chase the response. The investigation found that delays in making appointments and telephone consultations for Mr A between May 2021 and 23 November 2021 were unavoidable due to the COVID-19 pandemic and a telephone system that could not cope with the unprecedented demand, the quality of the 2 assessments Mr A underwent on 10 August and 7 September 2021 were appropriate and there was no reason to suspect cancer during the first assessment, downgrading Mr A’s USC referral following the second assessment was appropriate and in-line with national guidelines, and although the delay in the Health Board responding to Mrs C’s complaint was not in keeping with national guidance, she was, overall, regularly updated. The Health Board apologised to Mrs C for the delay. The Ombudsman did not uphold Mrs C’s complaint.

Mrs C complained about the care and management her late husband, Mr A, received from the GP Surgery (“the Surgery”) between May and November 2021. The Ombudsman investigated whether there were unacceptable delays in making appointments and telephone consultations for Mr A between May 2021 and 23 November 2021, and whether the quality of the assessment Mr A underwent on 10 August 2021 was appropriate and whether an alternative diagnosis of cancer should have been considered at that time. Mrs C also complained about the care and treatment Mr A received from Aneurin Bevan University Health Board (“the Health Board”). The Ombudsman investigated whether it was appropriate to downgrade Mr A’s “urgent suspected cancer” (“USC”) referral made by the Surgery on 8 September 2021 to “urgent”, and whether there was an unacceptable delay in the Health Board’s response to Mrs C’s complaint and to her attempts to chase the response. The investigation found that delays in making appointments and telephone consultations for Mr A between May 2021 and 23 November 2021 were unavoidable due to the COVID-19 pandemic and a telephone system that could not cope with the unprecedented demand, the quality of the 2 assessments Mr A underwent on 10 August and 7 September 2021 were appropriate and there was no reason to suspect cancer during the first assessment, downgrading Mr A’s USC referral following the second assessment was appropriate and in-line with national guidelines, and although the delay in the Health Board responding to Mrs C’s complaint was not in keeping with national guidance, she was, overall, regularly updated. The Health Board apologised to Mrs C for the delay. The Ombudsman did not uphold Mrs C’s complaint.

Mrs A complained about the care that her late father, Mr B, received following his admission to hospital. She complained that the decision to insert a catheter (a tube inserted into the bladder to allow urine to drain freely) and discharge him with it in place was not clinically appropriate. Mrs A also complained that there was a failure to consult with her or her brother (Mr C), who both held the authority to make decisions about Mr B’s health and welfare. The complaints were not upheld. The investigation found that the decision to insert the catheter was clinically appropriate based upon treatment Mr B was receiving for sepsis and because of the outcome of fluid balance monitoring. It was also necessary to discharge Mr B with the catheter in place because of Mr B’s reduced mobility, his prolonged stay in hospital and his difficulty emptying his bladder. The investigation also found that although the clinicians did not consult with Mrs A and Mr C, it was appropriate and reasonable to go ahead with catheterisation in Mr B’s best interests. This was because of the urgency of the situation in relation to sepsis, and because Mr B was not able to empty his bladder. Mr B was also showing signs of agitation. This improved following catheterisation. The Ombudsman did identify some issues with the documentation. She has invited the Health Board to consider those issues and Mrs A’s request to create, if one is not already in place, a guidance document on consultation with family members who have the authority to make health and welfare decisions.

Mr R complained about care and treatment provided to his late wife, Mrs R, by Aneurin Bevan University Health Board (“the Health Board”), a GP Practice (“the Practice”) in the area of the Health Board, and Gloucestershire Hospitals NHS Foundation Trust (“the First Trust”). The Public Services Ombudsman for Wales (“the PSOW”) and the Parliamentary and Health Service Ombudsman (“the PHSO”) jointly investigated Mr R’s complaints that there were failures by the above organisations to: a) Arrange appropriate investigations, treatment and/or referrals after Mrs R was found to have lymphadenopathy (swelling in the lymph nodes which are part of the immune system). b) Ensure that their clinicians adequately communicated and coordinated with other clinicians involved in Mrs R’s care. The investigation also considered the complaints that the Health Board failed to: c) Provide adequate care and treatment to manage Mrs R’s sepsis or risk of sepsis (when the body overreacts to an infection and damages the organs and tissue). d) Inform Mrs R’s family about her deterioration in time to enable a visit before she died. Complaint a) was not upheld in relation to the Practice and the Health Board. The investigation found that the First Trust’s investigation of Mrs R’s lymphadenopathy was unduly delayed. As a result, an opportunity was missed to arrange a biopsy which would have provided Mrs R with greater certainty about what was causing the deterioration of her health. Complaint a) was upheld in relation to the First Trust. The investigation found that while there were shortcomings in the way the Practice coordinated Mrs R’s care, it faced a difficult task because of the number of organisations involved and its lack of access to electronic patient information about care provided in England. Similarly, while the Health Board could have improved the way it communicated with its counterparts in England, its actions did not fall below the expected standards. Complaint b) was not upheld in

Mr R complained about care and treatment provided to his late wife, Mrs R, by Aneurin Bevan University Health Board (“the Health Board”), a GP Practice (“the Practice”) in the area of the Health Board, and Gloucestershire Hospitals NHS Foundation Trust (“the First Trust”). The Public Services Ombudsman for Wales (“the PSOW”) and the Parliamentary and Health Service Ombudsman (“the PHSO”) jointly investigated Mr R’s complaints that there were failures by the above organisations to: a) Arrange appropriate investigations, treatment and/or referrals after Mrs R was found to have lymphadenopathy (swelling in the lymph nodes which are part of the immune system). b) Ensure that their clinicians adequately communicated and coordinated with other clinicians involved in Mrs R’s care. The investigation also considered the complaints that the Health Board failed to: c) Provide adequate care and treatment to manage Mrs R’s sepsis or risk of sepsis (when the body overreacts to an infection and damages the organs and tissue). d) Inform Mrs R’s family about her deterioration in time to enable a visit before she died. Complaint a) was not upheld in relation to the Practice and the Health Board. The investigation found that the First Trust’s investigation of Mrs R’s lymphadenopathy was unduly delayed. As a result, an opportunity was missed to arrange a biopsy which would have provided Mrs R with greater certainty about what was causing the deterioration of her health. Complaint a) was upheld in relation to the First Trust. The investigation found that while there were shortcomings in the way the Practice coordinated Mrs R’s care, it faced a difficult task because of the number of organisations involved and its lack of access to electronic patient information about care provided in England. Similarly, while the Health Board could have improved the way it communicated with its counterparts in England, its actions did not fall below the expected standards. Complaint b) was not upheld in

Mrs S complained that Aneurin Bevan University Health Board had failed to respond to her complaint, submitted in August 2022. The Ombudsman found that the Health Board had provided a full response to concerns raised by Mrs S in December 2022, but had failed to address the earlier concerns that Mrs S had raised in August 2022. The Ombudsman sought and gained the Health Board’s agreement to provide a complaint response to Mrs S, addressing the issues raised in August 2022, within 20 working days.

Mr R complained about care and treatment provided to his late wife, Mrs R, by Aneurin Bevan University Health Board (“the Health Board”), a GP Practice (“the Practice”) in the area of the Health Board, and Gloucestershire Hospitals NHS Foundation Trust (“the First Trust”). The Public Services Ombudsman for Wales (“the PSOW”) and the Parliamentary and Health Service Ombudsman (“the PHSO”) jointly investigated Mr R’s complaints that there were failures by the above organisations to: a) Arrange appropriate investigations, treatment and/or referrals after Mrs R was found to have lymphadenopathy (swelling in the lymph nodes which are part of the immune system). b) Ensure that their clinicians adequately communicated and coordinated with other clinicians involved in Mrs R’s care. The investigation also considered the complaints that the Health Board failed to: c) Provide adequate care and treatment to manage Mrs R’s sepsis or risk of sepsis (when the body overreacts to an infection and damages the organs and tissue). d) Inform Mrs R’s family about her deterioration in time to enable a visit before she died. Complaint a) was not upheld in relation to the Practice and the Health Board. The investigation found that the First Trust’s investigation of Mrs R’s lymphadenopathy was unduly delayed. As a result, an opportunity was missed to arrange a biopsy which would have provided Mrs R with greater certainty about what was causing the deterioration of her health. Complaint a) was upheld in relation to the First Trust. The investigation found that while there were shortcomings in the way the Practice coordinated Mrs R’s care, it faced a difficult task because of the number of organisations involved and its lack of access to electronic patient information about care provided in England. Similarly, while the Health Board could have improved the way it communicated with its counterparts in England, its actions did not fall below the expected standards. Complaint b) was not upheld in

Mrs X complained that Aneurin Bevan University Health Board (“the Health Board”) failed to offer her treatment with the drug fampridine after its approval for NHS use in Wales in December 2019. Fampridine may help certain patients who have multiple sclerosis. I upheld the complaint. My investigation found that, despite fampridine being approved for NHS-funded use in Wales in 2019, the Health Board had still not put in place arrangements to offer fampridine to any eligible patients within its area. This included Mrs X. In my view, this amounted to maladministration which resulted in ongoing injustice to Mrs X. She remains unclear as to when or if she will have access to this potentially life improving medication. I recommended that the Health Board should apologise to Mrs X, and put in place an action plan, with timescales and board oversight, to ensure that the introduction of fampridine was implemented in a timely manner.

Mr A’s concerns related to the treatment and care of his late wife, Mrs A. He complained about his wife’s care during her inpatient admission at the Royal Gwent Hospital (“the Hospital”) between 15 March and 31 March 2020, the accuracy of his wife’s clinical records and the Health Board’s over-reliance on them. Finally, he also complained about the adequacy of the Health Board’s complaint response. The investigation found that overall the medical care Mrs A received in the emergency department was reasonable and appropriate as was her care in the intensive care unit. However, this was not the case with aspects of her later inpatient care. There were failures by the on-call Junior Doctor to recognise Mrs A’s low blood pressure, and appropriately treat her with fluids and the Surgical Doctor to recognise Mrs A’s deteriorating condition which included low blood pressure increasing NEWS and the possibility of an internal bleed. The omissions meant that Mrs A’s condition further deteriorated and the Ombudsman’s investigation concluded that this should have prompted an escalation of Mrs A’s care for senior surgical review. These shortcomings represented a significant clinical deficiency in Mrs A’s care. On the balance of probabilities, the Ombudsman was unable to rule out the possibility that earlier management and intervention could have led to a different outcome in terms of Mrs A’s subsequent cardiac arrest and severe kidney damage that followed her prolonged resuscitation. It meant that palliative chemotherapy treatment for Mrs A’s advanced cancer, which was diagnosed during her inpatient admission, was not an option because of the severity of her kidney damage. The Ombudsman concluded that the clinical failings in this case were fundamental and to that extent, unacceptable. The investigation found that the nursing care provided to Mrs A was broadly reasonable, however, some aspects – such as fluid management and monitoring – were not appropriate. Although the Ombudsm

Mr A complained that the Health Board refused to warn patients referred to the Erectile Dysfunction Therapy clinic in advance that they would be expected to be examined and counselled by female clinicians. He said that the Health Board hid the fact that it would be a female clinician by sending appointment letters that just referred to a clinic, unlike other disciplines which would include the name (and hence gender), of the clinician they would be seeing. Mr A said the examination was hugely humiliating and embarrassing. Mr A said that Welsh Government guidelines stated that a patient may request to have such an examination by a person of the same gender, but it was impossible to make such a request without being forewarned. The assessment was concerned that patients should be properly informed of the gender of the clinicians with which they would be attending a potentially gender sensitive clinic. Instead of investigating this complaint, the Ombudsman sought and gained the Health Board’s agreement to undertake the following action to resolve the complaint: • The Health Board agreed to amend the template for Erectile Dysfunction Therapy clinic appointment letters so that they include the name of the clinician holding the clinic and information regarding the service being female-led and informing the patient that they can contact the Urology Department for assistance should that concern them. The Health Board agreed to undertake these changes within 1 month.

Ms G complained that Aneurin Bevan University Health Board had failed to respond to the complaint she had made to it in May 2023. The Ombudsman found that there was a delay in the Health Board responding to Ms G’s complaint, which the Ombudsman said caused frustration to Ms G. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to apologise to Ms G for the delay and explain the reasons for it, and to offer a redress payment of £150 to Ms G, within 2 weeks. Additionally, the Health Board agreed to issue its complaint response to Ms G within 6 weeks.

Ms A complained about the care and treatment her mother received when in hospital. The Ombudsman found that the complaint response provided by the Health Board had not fully considered all aspects of Ms A’s concerns in line with relevant complaints guidance. Ms A had also indicated that she would like a meeting with relevant staff at the Health Board to discuss her concerns, and the Ombudsman considered it would be appropriate to undertake this before any investigation by this office. The Health Board therefore agreed to provide a further complaint response considering breach of care in relation to Ms A’s mother’s fracture, and further outlining the qualifying liability decision in relation to her missed medication, and to offer her a meeting with relevant staff to discuss the complaint, to take place within 30 working days.

Mr U complained that Aneurin Bevan University Health Board failed to respond to complaints submitted in February and June 2023. The Ombudsman found that the Health Board had complied with the Putting Things Right process but determined that there had been a significant delay in the Health Board concluding its investigation which caused additional frustration to Mr U. She therefore decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to issue a response within 3 weeks.

A solicitor complained on behalf of Ms A that Aneurin Bevan University Health Board had failed to respond to a complaint made to it in September 2022. The Ombudsman found that the Health Board had been chased for updates by the solicitor and had failed to provide a complaint response. The Ombudsman said this caused frustration for Ms A. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to apologise and explain the reasons for the delay, offer a £250 payment to Ms A, and to issue its complaint response within 8 weeks.

Miss A complained about the care and treatment provided to her mother, Mrs B, by the Health Board between 23 June and 23 July 2021. We investigated whether Mrs B received appropriate nutritional care; whether Mrs B’s oral care and ongoing diarrhoea were appropriately managed; whether Mrs B’s prognosis was appropriately communicated to Mrs B and her family when she received her diagnosis of cancer and whether discharge planning and palliative care input was appropriate following Mrs B’s cancer diagnosis. The Ombudsman found that Mrs B received appropriate nutritional and oral care and that communication about Mrs B’s diagnosis and prognosis was also appropriate. These complaints were not upheld. The Ombudsman found that the majority of Mrs B’s care in relation to the management of her diarrhoea was appropriate. However, she found that there was a delay in administering loperamide (a medication which reduces bowel activity and diarrhoea). Earlier administration might have reduced the effect of diarrhoea and might have made Mrs B more comfortable. This was an injustice to Mrs B and this aspect of the complaint was upheld. The Ombudsman found that whilst it was difficult to identify the best moment for transition from active to palliative care, on balance, a palliative care referral could have been considered sooner, which might have given Mrs B and her family reassurance and support. Even though Mrs B’s wish to return home was not achieved, this was not owing to inadequate discharge planning. Sadly, Mrs B’s rapid deterioration meant that she was too unwell to go home. The complaint was upheld to the extent that earlier palliative care input could have been considered. The Health Board agreed to apologise to Miss A for the identified failings and share the report with relevant staff involved in Mrs B’s care for reflection and learning, in particular around the delay in administering loperamide and the timing of palliative care referrals.

Mrs V complained that Aneurin Bevan University Health Board failed to provide a response to her complaint about the care and treatment provided to her late father which she made to it in April 2023. The Ombudsman found that the Health Board had failed to issue a complaint response and had not provided regular and meaningful updates. She said that 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 write to Mrs V with the necessary apologies and explanations for the oversights and to issue a complaint response within 2 weeks.