PSOW Individual Decisions

Ms Y complained that Aneurin Bevan University Health Board did not recognise the impact on her of a delay in having surgery to remove a rectal polyp (tissue growth from the wall of the rectum). Specifically, she complained that this had impacted her physically and mentally, including causing severe tissue damage, an increased risk of developing cancer and the need for an annual colonoscopy (a procedure using a narrow camera inserted through the anus). The Ombudsman found that there was an unreasonable delay in Ms Y having surgery to remove a rectal polyp. As a result, Ms Y had a prolonged period of discomfort and distress. Ms Y will also now have 1-year and 3-year post surgery surveillance procedures which may not have been required had her surgery been completed earlier. This is a service failure and injustice to Ms Y. This complaint was upheld. The Health Board agreed to apologise to Ms Y for the delay in her surgery and the impact this had on her. It also agreed to make a financial redress payment for the maladministration in mislaying her referral and the delay in her surgery of £750. Finally, it agreed to share the report and its findings with relevant clinicians to reflect on.

Miss X complained that the Health Board had failed to act when, during her pregnancy, she informed it of a family history of haemophilia. She said that this resulted in a lost opportunity for an antenatal diagnosis of haemophilia and subsequent specialist management, which put both herself and her child at risk. The Ombudsman found that whilst the Health Board had carried out an investigation into Miss X’s care, she had not received a formal complaint response. The Ombudsman decided to settle the complaint without an investigation and sought the Health Board’s agreement to provide a formal complaint response to Miss X within 30 days.

Ms A complained about the Gynaecology care and treatment provided to her by the Health Board. Specifically, she queried whether the diagnostic pathway for endometriosis was followed appropriately, and if the removal of her intrauterine device (“coil”) was carried out and documented appropriately, and in line with relevant guidance. She also complained about how the concerns she raised while still in hospital were addressed. The evidence indicated that the appropriate clinical diagnostic pathway was followed so the Ombudsman did not uphold this element of the complaint. The Ombudsman was unable to reach a definitive decision regarding Ms A’s consent to the removal of the coil. However, the investigation found that documentation around this discussion could have been improved, and elements of the complaint response addressing the procedure were incorrect. Therefore, this aspect of the complaint was upheld. The investigation found that, whilst Ms A’s concerns were discussed during her stay in hospital, given the seriousness of her complaint, this could have been done earlier. It would also have been beneficial to have referred her to the Patient Advice and Liaison Service (PALS), or given her advice on how to make a formal complaint. This part of the complaint was therefore partly upheld. The Ombudsman recommended the Health Board should apologise to Ms A for the failures identified and offer her a payment of £500 in acknowledgement of the failings in relation to recording of consent and how her complaint was handled. She also recommended that the Health Board should confirm that the Gynaecologist involved has discussed this case at his next appraisal. The Health Board also agreed to share the findings of the Ombudsman’s investigation at an appropriate Gynaecological Oncology consultant forum to ensure wider learning from the complaint, particularly the record keeping requirements around consent and obligation to provide correct information to complaint responses. She

Mrs A complained to Aneurin Bevan University Health Board about care and treatment provided to her late husband during his admission to hospital from September to November 2021. The Ombudsman found that the Health Board’s complaint response failed to address the majority of the issues raised by Mrs A. This constituted an injustice to Mrs A, who had not been provided with the answers to her questions about her husband’s care. The Ombudsman contacted the Health Board and in resolution of Mrs A’s complaint it agreed to, within 30 working days, fully investigate and respond to all aspects of Mrs A’s complaint submitted in September 2022, in accordance with The NHS (Concerns, Complaints and Redress Arrangements) (Wales) Regulations 2011.

Mr L complained that Aneurin Bevan University Health Board failed to respond to the complaint he submitted to it in September 2022. The Ombudsman found that the Health Board had failed to act in accordance with its statutory complaint’s procedure, and failed to provide meaningful updates to Mr L. She said this caused frustration to Mr L. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Boards agreement to provide Mr L with an apology and explanation for the delays encountered, issue a formal complaint response, and offer a time and trouble payment of £250 to address the delays within 4 weeks.

The Ombudsman investigated a complaint from Ms A about the care and treatment provided to her grandmother, Mrs B, by the Health Board, following her admission to hospital on 23 August 2021. The investigation focussed specifically on whether Mrs B was appropriately assessed, and her level of vulnerability documented, the failure to carry out a falls risk assessment and whether this resulted in Mrs B sustaining a fractured risk following a fall. The investigation also considered whether appropriate measures were put in place following Mrs B’s fall and whether her medical records were maintained to an appropriate standard. The Ombudsman found that there was a clear failure to recognise Mrs B as vulnerable and there was a failure to carry out a falls risk assessment. Whilst it was not possible to determine for certain whether Mrs B would not have fallen and sustained the injuries that she did, had her vulnerabilities been fully recognised and the risk assessment completed, the element of uncertainty about this issue, and whether it would have changed the course of events for Mrs B, constituted an injustice to Mrs B and her family. The Ombudsman upheld the complaint. The Ombudsman found that there was a failure to complete an enhanced care assessment correctly following Mrs B’s fall. However, as there was no evidence that Mrs B suffered any harm or injustice as a consequence of the service failure. The complaint was not upheld. The investigation found that record keeping fell below an adequate standard in respect of Mrs B’s clinical records. This included the failure to complete a falls risk assessment and a failure to document the special visiting arrangements put in place for Mrs B. As a consequence, Mrs B’s family members were denied visiting access, causing both distress to them and to Mrs B. This service failure represented an injustice to both Mrs B and her family. The Ombudsman upheld the complaint. In addition to action taken by the Health Board prior to the conc

Mrs A complained about the actions of Aneurin Bevan University Health Board (“the Health Board”) in relation to the care provided to her late mother, Mrs B. Specifically, Mrs A complained that Mrs B’s needs (as set out in her Care Plan) were not met, there was a failure to ensure appropriate assessments were undertaken in a timely manner and her return to her own home was inappropriately and unreasonably delayed, all of which impacted on her health and welfare. In addition, Mrs A complained about the care Mrs B received from a care home in the Health Board area (“the Care Home”) in that, between 1 and 28 November 2020, the Care Home did not meet Mrs B’s needs (as set out in her Care Plan) and did not ensure its staff used Personal Protective Equipment (“PPE”) appropriately and in-line with legislation and guidance. The Ombudsman found that there were some shortcomings on the part of both the Health Board and Care Home, in meeting the needs set out in the Care Plan, but that this was largely due to measures needed to stop transmission of the COVID-19 infection. The Ombudsman did not uphold these complaints. The Ombudsman found that although appropriate assessments were completed, there were avoidable delays in the assessment and discharge process and so, to that extent, upheld this complaint. The Ombudsman also found that for a period of time while Mrs B was in the Care Home, and while she was nursed in a bed, the Care Home did not to adhere to her Care Plan. The Ombudsman also found that although it was not possible to say the extent to which this was the case, the correct PPE was not appropriately worn consistently in the communal areas of the Care Home. The Ombudsman upheld this complaint. The Ombudsman recommended that, within 1 month, both the Health Board and Care Home apologise to Mrs A for the failings identified.

Mrs A complained about her late husband, Mr B, not being given an opportunity to use a continuous positive airway pressure (“CPAP”) machine (to assist with breathing difficulties during sleep), while an inpatient at the Royal Gwent Hospital and the Grange University Hospital, despite its use being authorised by his Consultant. In particular, she was concerned that her husband not using a CPAP machine could have contributed to or exacerbated the heart disease from which he died. She also complained about poor communication by the Care after Death Team and the delay in that team making a referral to the Coroner’s office. Finally, she expressed dissatisfaction with Aneurin Bevan University Health Board’s complaint handling and the adequacy of the response. The investigation found that not using a CPAP machine played no significant role in Mr B’s cardiac arrest. However, his comfort was affected and to this extent he was caused an injustice. The investigation concluded that communication could have been more effective and whilst the Health Board’s complaint response was broadly reasonable and appropriate, more could have been done to address issues around communication, and to have highlighted service change improvements in the Care after Death Team. The injustice to Mrs A included the distress caused and having to pursue her complaint further to get answers. Mrs A’s complaints were upheld to limited extents. The Ombudsman recommended that the Health Board apologise to Mrs A and that the Care after Death Team review Mrs A’s complaint to see if there were any lessons to be learnt in relation to communication, especially when a case is being considered by a medical examiner.

Mrs A complained about the actions of Aneurin Bevan University Health Board (“the Health Board”) in relation to the care provided to her late mother, Mrs B. Specifically, Mrs A complained that Mrs B’s needs (as set out in her Care Plan) were not met, there was a failure to ensure appropriate assessments were undertaken in a timely manner and her return to her own home was inappropriately and unreasonably delayed, all of which impacted on her health and welfare. In addition, Mrs A complained about the care Mrs B received from a care home in the Health Board area (“the Care Home”) in that, between 1 and 28 November 2020, the Care Home did not meet Mrs B’s needs (as set out in her Care Plan) and did not ensure its staff used Personal Protective Equipment (“PPE”) appropriately and in line with legislation and guidance. The Ombudsman found that there were some shortcomings on the part of both the Health Board and Care Home, in meeting the needs set out in the Care Plan, but that this was largely due to measures needed to stop transmission of the Covid-19 infection. The Ombudsman did not uphold these complaints. The Ombudsman found that although appropriate assessments were completed, there were avoidable delays in the assessment and discharge process and so, to that extent, upheld this complaint. The Ombudsman also found that for a period of time while Mrs B was in the Care Home, and while she was nursed in a bed, the Care Home did not to adhere to her care plan. The Ombudsman also found that although it was not possible to say the extent to which this was the case, the correct PPE was not appropriately worn consistently in the communal areas of the Care Home. The Ombudsman upheld this complaint.

Mrs T complained that Aneurin Bevan University Health Board failed to issue a complaint response to her by the date it had agreed in a previous early resolution with the Ombudsman’s office. It also failed to meet an extended deadline to issue the response. The Ombudsman decided there had been an unacceptable delay in the Health Board responding to Mrs T and this had caused additional frustration for her. The Ombudsman sought and gained the Health Board’s agreement to provide Mrs T with further redress of £100 and provide its complaint response within 2 weeks. The Ombudsman accepted these actions as an alternative to issuing a Special Report.

Mr C has complained about the care and treatment his wife, Mrs A, received from Aneurin Bevan University Health Board (“the Health Board”) when she presented to the Emergency Department (“the ED”) at Grange University Hospital (“the Hospital”) in January 2021. He complained about the failure to diagnose Mrs A’s first stroke when she presented to the ED on 25 January 2021; as well as failings in nursing and medical care during the weekend of 19 February around a stroke diagnosis. Finally, he was dissatisfied with the Health Board’s complaint handling and the robustness of its complaint response. The investigation found that based on Mrs A’s symptoms it might have been reasonable to consider if a small stroke had occurred during her January admission. Given this, she should not have been discharged until discussions had taken place with other relevant clinicians such as the stroke specialists, neurologists and radiologists and further examination, specifically a doppler ultrasound, carried out. The Ombudsman was also concerned that a key clinical discussion with Mrs A about being discharged, and an MRI and other investigations being carried out as an outpatient was not documented in Mrs A’s clinical records. In the absence of such documentation, it was not possible to say that such a discussion took place. The investigation concluded that this administrative failing was not only maladministrative but was also not in-keeping with the General Medical Council’s guidance on record-keeping. That said, the Ombudsman was satisfied that any delay in treatment planning would not have altered Mrs A’s outcome. The service failings identified meant that Mrs A and her family would be left with the uncertainty of not knowing whether she suffered a small stroke during this admission. Consequently, they were less prepared than they might have been when she suffered a major stroke following her discharge home and this was an injustice to Mrs A and her family. It was to this limited ex

Mrs D complained about the care and treatment provided to her husband, Mr D, by Aneurin Bevan University Health Board (“the Health Board”) and his GP Practice. Mrs D’s complaint that the GP Practice missed opportunities to carry out assessments, investigations and/or referrals that would have led to the earlier identification of Mr D’s cancer was partially upheld. The investigation found that the clinical treatment provided to Mr D by the Practice prior to 21 December was appropriate. However, it found that there was a failure to send a stool sample for analysis which meant that GPs assessing Mr D’s symptoms were deprived of potentially significant clinical information. The investigation found that there was a failure to make an urgent suspected cancer referral on 21 December which placed Mr D at avoidable risk of harm. The Ombudsman also upheld Mrs D’s complaints that the Health Board failed to investigate and treat Mr D’s cancer in a timely and appropriate manner and failed to keep Mr D appropriately informed about and involved with decisions about his care. The investigation found that there was an unreasonable delay by the Health Board in the investigation of Mr D’s symptoms following a GP referral on 11 August 2021. Although it was not possible to say whether his cancer would have been diagnosed earlier, this missed opportunity was an injustice to Mr D. The investigation also found that there was a failure by the Health Board to provide appropriate communication and support for Mr D following his cancer diagnosis, causing him avoidable distress. The Practice agreed to the Ombudsman’s recommendations to apologise and make a financial redress payment to Mrs D of £250, and to share the report and learning points with relevant clinicians. The Health Board agreed to the Ombudsman’s recommendations to apologise and make a financial redress payment to Mrs D of £750, to share the report and learning points with relevant clinicians, and to review its process for listing

Mrs D complained about the care and treatment provided to her husband, Mr D, by Aneurin Bevan University Health Board (“the Health Board”) and his GP Practice. Mrs D’s complaint that the GP Practice missed opportunities to carry out assessments, investigations and/or referrals that would have led to the earlier identification of Mr D’s cancer was partially upheld. The investigation found that the clinical treatment provided to Mr D by the Practice prior to 21 December was appropriate. However, it found that there was a failure to send a stool sample for analysis which meant that GPs assessing Mr D’s symptoms were deprived of potentially significant clinical information. The investigation found that there was a failure to make an urgent suspected cancer referral on 21 December which placed Mr D at avoidable risk of harm. The Ombudsman also upheld Mrs D’s complaints that the Health Board failed to investigate and treat Mr D’s cancer in a timely and appropriate manner and failed to keep Mr D appropriately informed about and involved with decisions about his care. The investigation found that there was an unreasonable delay by the Health Board in the investigation of Mr D’s symptoms following a GP referral on 11 August 2021. Although it was not possible to say whether his cancer would have been diagnosed earlier, this missed opportunity was an injustice to Mr D. The investigation also found that there was a failure by the Health Board to provide appropriate communication and support for Mr D following his cancer diagnosis, causing him avoidable distress. The Practice agreed to the Ombudsman’s recommendations to apologise and make a financial redress payment to Mrs D of £250, and to share the report and learning points with relevant clinicians. The Health Board agreed to the Ombudsman’s recommendations to apologise and make a financial redress payment to Mrs D of £750, to share the report and learning points with relevant clinicians, and to review its process for listing

Mrs C complained that Aneurin Bevan University Health Board failed to respond to a complaint she made in December 2022. The Ombudsman decided there had been a delay in the Health Board’s response and this caused inconvenience and frustration for Mrs C. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to apologise to Mrs C and pay her £50 redress in recognition of the delay. The Health Board also agreed to provide Mrs C with a complaint response within 4 weeks.

Mr X complained that Aneurin Bevan University Health Board failed to respond to the complaint he submitted in January 2023. He also complained about poor communication and a lack of regular updates from the Health Board. The Ombudsman decided that there had been a delay in the Health Board’s response and it had failed to update Mr X. She said this caused frustration and uncertainty to Mr X. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to apologise to Mr X and provide him with a complaint response within 3 weeks.

Mrs T complained that Aneurin Bevan University Health Board failed to respond to a complaint she submitted in August 2022. The Ombudsman decided that there had been a delay in the Health Board’s response and this caused inconvenience and frustration for Mrs T. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to apologize to Mrs T and provide her £100 in recognition of the time and trouble spent in approaching the Ombudsman. The Health Board also agreed to provide Mrs T with a complaint response within 3 weeks.

Ms A complained that Aneurin Bevan University Health Board had failed to respond to her complaint, which was made to it in January 2023, and had failed to provide updates to her. The Ombudsman considered that there had been a delay in providing a response to Ms A’s complaint and the Health Board had failed to provide regular or meaningful updates to Ms A. The Ombudsman contacted the Health Board and it agreed to undertake the following actions within 12 weeks to resolve the complaint and as an alternative to a formal investigation: · Apologise to Ms A for the delay and failure to update her, and explain the reasons for this. · Issue its complaint response. · Offer Ms A £75 for the time and trouble in making her complaint to the Ombudsman’s office.

Mrs A complained about the management and care her mother Mrs B received at Ysbyty Ystrad Fawr and later at Grange University Hospital managed by Aneurin Bevan University Health Board (“the Health Board”). Mrs A complained that when her mother became unwell after her discharge home on 10 July 2021, she should have been re-admitted to the First Hospital on 12 July and that her mother’s discharge on 27 July following an inpatient admission was unsafe. Mrs A also complained about the poor communication with the family about her mother’s end of life care. Finally, Mrs A said that there was a delay in complaint handling, due to her original complaint not being registered and felt the complaint response was not robust. The Ombudsman’s investigation found that when Mrs A’s mother became unwell after her discharge home on 10 July, she should have been re-admitted to Ysbyty Ystrad Fawr hospital on 12 July for further assessment. Whilst the failure to admit Mrs B was a service failure, the Ombudsman was satisfied that this did not lead to any significant harm. The Ombudsman was also satisfied that clinically Mrs B’s discharge was safe and that communication with Mrs A and her family about Mrs B’s end of life care was appropriate and reasonable. These aspects of Mrs A’s complaint were not upheld. The Ombudsman concluded that the Health Board’s investigation and subsequent complaint response was not sufficiently robust since it did not identify/address the shortcomings around the mismanagement of Mrs A’s complaint. To this limited extent only this aspect of Mrs A complaint was upheld and a financial redress of £250 recommended.

Mrs A complained about care and treatment provided to her daughter, Miss B, by Aneurin Bevan University Health Board’s (“the Health Board”) Mental Health Service. The investigation considered whether Miss B’s care between July 2020 and September 2021 (both in the community and as an inpatient) was generally appropriate, whether account was taken of Miss B’s autism, and adjustments made for this in the way in which people worked/communicated with her and whether Miss B’s discharge from hospital in September 2021, without accommodation arrangements being made, was appropriate. The Ombudsman found that the care and treatment provided to Miss B between July 2020 and September 2021 was clinically appropriate. The Ombudsman did not uphold the complaint.

Mrs X complained about the standard of care and treatment provided to her late husband, Mr X, after he tested positive for COVID-19. Specifically, she complained that opportunities to treat him, as a vulnerable patient, with antiviral medication were missed. Mrs X was concerned that he should not have been initially discharged from the Grange University Hospital and that additional treatment should have been given to him for COVID-19. She complained that he was prescribed antibiotics by the GP following a telephone consultation as opposed being seen by the GP. When Mr X was later admitted to the University Hospital of Wales with COVID-19 symptoms, Mrs X felt that the provision of antiviral treatment was delayed. The Ombudsman found that the decision to discharge Mr X from the Grange University Hospital was reasonable as Mr X had not required any specific hospital treatment for COVID-19 at that point. His condition had not met the national criteria for prescribing antiviral medication. On admission to the University Hospital of Wales, Mr X’s condition had deteriorated, and he was assessed as needing the antiviral treatment. This was prescribed within an appropriate timescale. The prescribing of antibiotics by the GP was appropriate as it was based on a detailed history and telephone assessment of Mr X’s presenting symptoms. The Ombudsman found no failings in the care provided and did not uphold the complaints.

Mrs X complained about the standard of care and treatment provided to her late husband, Mr X, after he tested positive for COVID-19. Specifically, she complained that opportunities to treat him, as a vulnerable patient, with antiviral medication were missed. Mrs X was concerned that he should not have been initially discharged from the Grange University Hospital and that additional treatment should have been given to him for COVID-19. She complained that he was prescribed antibiotics by the GP following a telephone consultation as opposed being seen by the GP. When Mr X was later admitted to the University Hospital of Wales with COVID-19 symptoms, Mrs X felt that the provision of antiviral treatment was delayed. The Ombudsman found that the decision to discharge Mr X from the Grange University Hospital was reasonable as Mr X had not required any specific hospital treatment for COVID-19 at that point. His condition had not met the national criteria for prescribing antiviral medication. On admission to the University Hospital of Wales, Mr X’s condition had deteriorated, and he was assessed as needing the antiviral treatment. This was prescribed within an appropriate timescale. The prescribing of antibiotics by the GP was appropriate as it was based on a detailed history and telephone assessment of Mr X’s presenting symptoms. The Ombudsman found no failings in the care provided and did not uphold the complaints.

Ms V complained that Aneurin Bevan University Health Board had failed to respond to a complaint she submitted in September 2022. The Ombudsman decided that there had been a significant delay in the Health Board’s response and this caused inconvenience and frustration for Ms V. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to apologise to Ms Vand offer her redress of £75 in recognition of the delays. The Health Board also agreed to provide the complaint response within one week.

Mr K complained that Aneurin Bevan University Health Board failed to respond to a complaint submitted in July 2022. The Ombudsman found there to have been a significant delay in the Health Board issuing its complaint response. This caused additional frustration and inconvenience to Mr K. The Ombudsman decided to settle the complaint without an investigation. She sought and gained the Health Board’s agreement to issue its complaint response no later than 30 September 2023.

Mrs A complained that Aneurin Bevan University Health Board failed to provide a response to her complaint which she made 9 months ago. The Ombudsman found that there had been a delay in the Health Board issuing a complaint response. 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 Boards agreement to write to Mrs A with an apology and explanation for the delay in issuing a complaint response, offer to pay £75 redress for her time and trouble in bringing her complaint to the Ombudsman and issue a response within 2 weeks.

Mr B’s complaint related to the standard of care provided in June 2021 to his late mother, Mrs A, when she was transferred from ICU (the Intensive Care Unit) to ward-based care. Specifically, he raised concerns about the arrangements for handover to the ward, and whether Mrs A received appropriate pain assessment and medication on the ward following the transfer. The Ombudsman found that a referral to the Palliative Care team should have been made prior to Mrs A’s discharge from ICU. This would have helped ensure continuity of care for the planned transfer to ward care. This part of the complaint was upheld. In relation to the medication given, the Ombudsman found that ward staff continued the same medication regime, using the same medication and pain assessment charts, started in ICU. The evidence indicated regular assessment for pain and administration of medication when needed, and this aspect of the complaint was not upheld. The Health Board confirmed that, as a result of the complaint, it had reviewed its checklist on discharge from ICU to enable smooth transfers to ward-based care. This included ensuring that a referral to the Palliative Care team had been made for relevant patients. It had also provided additional palliative care training for staff and was considering implementing a behavioural pain assessment tool.