PSOW Individual Decisions

Ms X complained that Aneurin Bevan University Health Board failed to respond to a complaint submitted in August 2022. The Ombudsman found there had been a significant delay in the Health Board concluding its investigation. This caused additional frustration and uncertainty to Ms X. The Ombudsman decided to settle the complaint without an investigation. She sought and gained the Health Board’s agreement to issue its complaint response by 31 August 2023.

Mrs A complained about her late mother’s care and management, when she presented to the Emergency Department on 16 February 2022 and her subsequent death. Mrs A said that the Health Board did not apologise to her for the failings in her mother’s care as part of its Serious Incident Review (“SIR”) and she did not feel that lessons had been learnt or that measures had been put in place to prevent similar occurrences. The Health Board agreed to provide an apology to Mrs A and her family for the shortcomings in the management and care of their late mother as well as providing a full explanation of the measures introduced as a result. In addition, the Health Board agreed to apologise to the family for shortcomings around its complaint processes when it came to complaint handling. 4 August 2023

Ms A complained that appropriate gynaecological investigations including around her urinary stress incontinence had not been carried out in a timely and reasonable manner. She was also dissatisfied with the way that referrals had been handled and the Health Board’s handling of her complaint. The Ombudsman found a substantial delay in one referral being taken forward. The referral was made in November 2018 but the response was not received until June 2020, and only chased by the Gynaecologist in May 2020, after Ms A raised it. There was also no explanation given for the delay either in the medical records or in the Health Board’s complaint response. The Ombudsman also found that the process behind the Gynaecologist’s letter to Ms A’s GP, about an incidental abdominal scan finding of fatty liver, did not accord with the British Medical Association’s (“BMA”) guidance. This was because no discussion had taken place with the GP to get their prior agreement to take forward this aspect of Ms A’s care and treatment. The Ombudsman concluded that the Health Board’s complaint response was not sufficiently robust on this point, nor did the Health Board’s policy appear in keeping with the BMA’s guidance. As part of the settlement the Health Board agreed to apologise for the shortcomings identified around the referrals and complaint handling and to provide an explanation for the delayed referral. Finally, the Health Board agreed to review its processes to see if lessons could be learnt regarding the delayed referral and to review, and if necessary update its policy, to reflect BMA guidance and to update its clinicians accordingly.

Ms S complained that Aneurin Bevan University Health Board failed to issue a further response to her complaint and had not communicated effectively during its investigation. The Ombudsman found that there had been a delay in the Health Board issuing a further response. Furthermore, the Health Board had not responded to requests for updates and had failed to provide regular and meaningful updates. She said this caused frustration and uncertainty to Ms S. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Boards agreement to provide the necessary apologies and explanations to Ms S for the oversights, offer to pay £75 redress for the time and trouble in making her complaint to the Ombudsman and issue a further response within 2 weeks.

Ms B complained about the care and treatment provided by a GP Practice in the area of Aneurin Bevan University Health Board. She complained that when she presented at the Practice on 11 June 2020 with a lump in her left breast, she was reassured that it was a benign cyst that required only monitoring. When she re-presented on 22 September, concerned that the lump had grown, she was examined by a different GP who, without any obvious means of comparison, assured her that the lump had decreased in size. When she informed the Practice on 14 December that the lump had increased in size and that she had detected a second lump in her left armpit, it was 3 February 2021 before she was seen by a breast specialist. Ms B complained that contrary to established guidance, GPs failed to make this referral under the appropriate urgent suspected cancer (“USC”) pathway. The Ombudsman found that the care provided at the consultation of 11 June was below an adequate standard as a referral should have been made at this point, under the USC pathway. This caused a significant injustice to Ms B as, had her cancer been diagnosed at this time, she could have been counselled against becoming pregnant and avoided being in the difficult and avoidable position whether to delay cancer treatment to complete her pregnancy or to have a termination. Similarly, had referral and diagnosis been made sooner, she may have elected to accept a short delay in treatment to pursue the option of harvesting her eggs with a view to using them in the future for IVF. This aspect of the complaint was therefore upheld. The investigation found that the care provided at the consultation of 22 September was below an adequate standard as there was a failure to properly record the size of the lump identified and because there should have been an USC referral this aspect of the complaint was upheld. The Ombudsman found that the USC referral made on 14 December was appropriate and in accordance with the USC pathway and th

Mr A complained about the treatment he received from the Health Board between 2019-2021. The investigation considered whether treatment of Mr A’s spinal injury while in the Emergency Department was appropriate, specifically his first assessment, the initial decision to discharge him; whether appropriate checks were conducted after he fell from bed in hospital; his aftercare for his back fracture, and if the information about his recovery period and advice provided was appropriate and the pain medication prescribed was sufficient. It also considered if the investigations undertaken in relation to his urology issues were sufficient and if the delay in his ADHD referral and appointments were excessive. The investigation found that the majority of Mr A’s spinal treatment was appropriate. However, further checks should have been done before the initial decision was made to discharge him home from the ED, painkillers should have been prescribed earlier, further X-rays should have been done, information about his recovery should have been detailed in his records and discharge letters, and pain management medication prescribed in hospital should have been continued upon discharge. Whilst there was no evidence to suggest any of these had a significant effect on Mr A’s overall recovery, together they were indicative of service failure and an injustice to Mr A, so this complaint was upheld. The investigations undertaken in relation to Mr A’s urology issues were found to be appropriate, and, although there was some delay in undertaking an ADHD referral, there was a clear rationale for this and the delay was not excessive. These complaints were not upheld. The Ombudsman recommended that the Health Board should provide Mr A with a written apology in relation to the shortcomings identified in the report, and should also remind relevant staff of the necessity of recording important information in relevant documentation. She also recommended that it should bring the investigation to

Ms K complained that Aneurin Bevan University Health Board failed to issue a complaint response regarding the care and treatment provided to her late mother. Ms K said that the next of kin provided consent over the telephone to the Health Board on the day she attended a meeting to discuss her concerns. Ms K said that consent was provided by the next of kin, however, the Health Board said it had not been received. The Ombudsman has been unable to reconcile the two different accounts in a way which would allow her to reach a definitive finding. The Ombudsman found that the Health Board had not been clear about the consent issue throughout its dealings with Ms K. Prior to Ms K attending the meeting she had been informed that her complaint had been closed due to the Health Board not receiving the necessary consent from the next of kin. Ms K was subsequently incorrectly informed after attending the meeting that a complaint response would be provides, and the Health Board failed to notify Ms K that no response would be issued when it realised its error. She said this caused uncertainty and frustration to Ms K. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to apologise to Ms K for the confusion and agreed to issue a complaint response if the necessary consent is received within 2 weeks.

Mrs B complained about the care and treatment that her late mother, Mrs C, received from the Health Board when she was admitted to hospital in October 2020. The investigation considered whether appropriate risk assessments, supervision, and care plans were put in place for Mrs C, particularly in relation to falls suffered during Mrs C’s time in hospital. It also considered whether Mrs C’s clinical treatment in relation to infections she contracted while in hospital were appropriate, and if communication with Mrs C’s family was sufficient during the course of her admission (approximately 11 weeks). The investigation found that the care provided to Mrs C between 13 October and 28 December 2020 fell below a reasonable standard. Whilst the clinical treatment Mrs C received in relation to the infections, she had contracted was reasonable (and this element of the complaint was not upheld), appropriate risk assessments, supervision and care plans were not adequately put in place and the communication with Mrs C’s family was not sufficient. This caused injustice to both Mrs C and Mrs B, and these elements of the complaint were therefore upheld. The Ombudsman recommended that the Health Board should provide Mrs B with a written apology for the failings identified in the report and offer her £500 in recognition of the communication issues. She recommended that the final report should be brought to the attention of the nursing team, with the identified issues highlighted, and that the team should be reminded of the expected level and method of communication for updates to families, particularly when visiting is restricted. She also recommended that the Health Board should consider whether refresher training is needed in relation to risk and enhanced care assessments, and that ward management staff should be reminded of the need to review enhanced care levels daily and to ensure that the rationale for changing the level of care is clearly documented. Finally, the Ombudsman reco

Mrs A said that the Health Board had not fully responded to her complaint about the care provided to her husband. The assessment found that the response did not appear to address care supplied by the Gastroenterology Department. The Health Board agreed to provide a response from that department within 8 weeks.

Ms A complained about the Dental Practice’s care and management provided to her mother, Dr A, since October 2020. Ms A said that the Practice unreasonably withdrew services because she complained. Ms A also complained about the Dental Practice’s handling of her complaint. The Ombudsman found that aspects of the Dental Practices’ care and management were reasonable and appropriate. However, the Ombudsman found that X-rays were not carried out, or that the reasons for not doing so were not documented. This aspect of Ms A’s complaint was upheld. The Ombudsman upheld Ms A’s complaint about the Dental Practice’s complaint handling. The Ombudsman was satisfied that dental services were not withdrawn because Dr A complained. This aspect of the complaint was not upheld. The Dental Practice agreed to implement the Ombudsman’s recommendations and apologise to Ms A and Dr A for the identified shortcomings, to review its complaints handling to ensure compliance with the accepted complaints handling process and to review guidance relating to the frequency of X-rays for patients with differing levels of risk as part of the dentists continuing professional development.

Mrs A complained about the care and treatment that her late mother, Mrs X, received during her admission from 13 July 2020 until 9 August 2020 (the day of her death). Specifically, that clinicians failed to facilitate her having direct telephone contact with her mother, that this lack of contact exacerbated Mrs X’s confused condition and the decision to address this with antipsychotic medication was not appropriate, that a Deprivation of Liberty Safeguard (“DoLS”) authorisation completed in respect of Mrs X failed to adhere to legal and regulatory requirements, and that the Health Board had not adequately explained the rapidity of Mrs X’s physical and psychological decline, which occurred within a matter of days of her admission. The investigation found that more should have been done to facilitate telephone contact between Mrs A and Mrs X. This avoidable distress was an injustice to Mrs A and Mrs X. This part of the complaint was upheld. The investigation found that the use of an antipsychotic was appropriate and in accordance with recognised guidance. However, communication with Mrs A about Mrs X’s treatment was poor and the lack of contact between Mrs A and Mrs X may have increased the distress and confusion Mrs X suffered. This was an injustice to Mrs X, and the uncertainty this leaves Mrs A with about the quality of her mother’s care is an injustice to Mrs A. This complaint was upheld to that extent. The investigation found that the urgent DoLS referral was appropriate and made in the best interests of Mrs X. This aspect of the complaint was not upheld. The investigation found that communication with Mrs A was extremely poor and fell well below the standard she should have received. This complaint was upheld. The Ombudsman recommended that the Health Board provide Mrs A with a written apology for the failings identified in this report and remind staff who care for patients with dementia of the requirements and benefits of good communication with families/carers

Mr A complained about the care and treatment provided to his late wife, Mrs A. In particular, Mr A complained that the Health Board failed to: • Take appropriate measures to prevent and manage skin damage during Mrs A’s hospital admission between 13 May and 21 June 2021; • Put in place an appropriate plan of care to prevent and manage further skin damage prior to Mrs A’s discharge from hospital on 21 June 2021; • Provide appropriate community-based care for Mrs A’s skin damage between June and September 2021; and • Arrange a timely referral to the tissue viability service in relation to Mrs A’s skin damage. The investigation found that following Mrs A’s discharge on 21 June, the district nursing referral was delayed and incomplete and that she suffered an injustice as a result. Accordingly, the Ombudsman upheld that part of the complaint. The investigation found that, otherwise, the care and treatment provided to Mrs A during her admissions to hospital between May and October 2021 and the district nursing care provided was reasonable and appropriate. For that reason, the remaining complaints were not upheld. The Health Board agreed to the Ombudsman’s recommendations to apologise to Mr A for the failings and injustice identified and to remind relevant staff of the importance of making timely and complete referrals for district nursing care when arranging the discharge of patients who are at very high risk of pressure damage.

Mr L complained that although he raised concerns about along history of miscommunications and cancellations of emergency eye surgery in October 2022, he had not yet received a response. The Ombudsman concluded that there had been a significant delay from the Health Board in issuing Mr L with a response, and that it had failed to respond to several update requests. She said this caused frustration to Mr L. As an alternative to an investigation, the Ombudsman sought and gained the Health Boards agreement to provide Mr L with an apology and explanation for the delays, issue a complaint response, and issue a time and trouble payment of £150 within 30 working days.

Ms C complained about the care and management she received from her GP Practice (“the Practice”) between 23 October 2020 and December 2021. She complained that a GP (“the First GP”) failed to recognise abnormal cholesterol result, to provide support and assessment when she requested a nutrition supplement. She complained that at another consultation another GP (“the Second GP”) and the Asthma Nurse had not listened/understood her condition, and that the Advance Nurse Practitioner told her to leave the premises following her attendance at the Practice. Ms C also complained about the cardiology care and treatment she received from the Health Board in 2020, in that it failed to identify that her Emergency Department attendances in October/November 2020 were related to her heart condition. Ms C complained that she was not referred to a cardiologist, which led to a deterioration in her health and delay in receiving treatment. Finally, she complained that the Health Board’s complaint response was not robust. The Ombudsman found that the care and management Ms C received from the Practice and from the Health Board’s Cardiology Department was appropriate. The Ombudsman was also satisfied that the Health Board’s complaint handling accurately reflected the care provided to Ms C. Ms C’s complaints were not upheld.

Mrs A’s father, Mr B, suffered from severe anxiety and had a fear of hospitals. She complained the Health Board ignored his request to arrange his own transport from hospital to Velindre Cancer Centre. Also, that the Health Board failed to recognise Mr B’s right to autonomy by transporting him and using restraining equipment against his wishes. The Ombudsman noted the Health Board had already acknowledged that there was a lack of documented evidence of conversations with Mr B and/or his family, and it could not confirm whether a risk assessment was completed by the Surgical Team. As an alternative to investigating the complaint, the Ombudsman sought and obtained the Health Board’s agreement to, within 20 working days, provide Mrs A with a further written apology that the experience gave her cause to complain; share the complaint with the nursing teams to provide an opportunity for learning and reflective practice on a patient’s right to autonomy; remind the nursing teams of the importance of ensuring documentation is fully completed and that patients are involved in their care to allow them to make informed decisions.

Ms C complained about the care and management she received from her GP Practice (“the Practice”) between 23 October 2020 and December 2021. She complained that a GP (“the First GP”) failed to recognise abnormal cholesterol result, to provide support and assessment when she requested a nutrition supplement. She complained that at another consultation another GP (“the Second GP”) and the Asthma Nurse had not listened/understood her condition, and that the Advance Nurse Practitioner told her to leave the premises following her attendance at the Practice. Ms C also complained about the cardiology care and treatment she received from the Health Board in2020, in that it failed to identify that her Emergency Department attendances in October/November 2020 were related to her heart condition. Ms C complained that she was not referred toa cardiologist, which led to a deterioration in her health and delay in receiving treatment. Finally, she complained that the Health Board’s complaint response was not robust. The Ombudsman found that the care and management Ms C received from the Practice and from the Health Board’s Cardiology Department was appropriate. The Ombudsman was also satisfied that the Health Board’s complaint handling accurately reflected the care provided to Ms C. Ms C’s complaints were not upheld.

Miss H complained that Aneurin Bevan University Health Board had failed to provide her with a response to a follow up complaint she submitted in October 2022. The Ombudsman decided that there had been a significant delay in the Health Board’s response which had caused inconvenience and frustration for Miss H. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to apologise to Miss H and offer her redress of £100 in recognition of the delay. The Health Board also agreed to issue the complaint response within 3 weeks.

Ms S complained that Aneurin Bevan University Health Board failed to provide appropriate care to her late mother. She further complained that although the Health Board had advised further investigations were being conducted into her mother’s care, she had not yet received a response. The Ombudsman found that the Health Board had agreed to further investigate Ms S’ concerns, but it had not kept her updated with its investigation, or provided her with a timescale. The Ombudsman said this caused further frustration and grief to Ms S. As an alternative to an investigation, the Ombudsman sought and gained the Health Board’s agreement to provide Ms S with an apology for the delays encountered, issue any outstanding responses, and issue a time and trouble payment of £250 within 6 months.

Ms X complained about care provided to her mother, Mrs Y, following her attendance for a bronchoscopy on 20 April 2021 and specifically whether: • the bronchoscopy was carried out appropriately • Mrs Y received appropriate after-care following the procedure, in particular, whether the decision to discontinue her antibiotics on 24 May was reasonable. The Ombudsman found that Mrs Y’s bronchoscopy was performed to a reasonable standard and that the risk of infection was indicated to Mrs Y on the consent form prior to the procedure. The Ombudsman found that the resulting appointments Mrs Y had with the Health Board provided appropriate after-care. The failure to start antibiotics on 26 April and not continuing antibiotics beyond 24 May were reasonable decisions that were, sadly, unlikely to have changed the course of events in this case. The complaint was not upheld.

Mr A complained to Aneurin Bevan University Health Board (“the Health Board”) about care and treatment provided to his late wife, Mrs A, by it, Cardiff and Vale University Health Board (“CAVUHB”) and Welsh Ambulance Service NHS Trust (“WAST”). Mr A complained to the Ombudsman that following the Health Board’s response, he had not received answers to all of the questions he raised. The Ombudsman found that the Health Board took the lead in terms of co-ordinating a joint investigation/response to Mr A, in conjunction with CAVUHB and WAST. However, not all of Mr A’s concerns about CAVUHB had been addressed and he had not received any response at all from WAST. Whilst the Health Board explained that WAST normally issue a separate complaint response, there was still a duty on it to ensure that Mr A received a co-ordinated response to his complaint, which the Health Board had failed to do. In resolution of Mr A’s complaint, the Health Board agreed to, within 30 working days, provide him with a written apology for the failure to provide a co-ordinated response, which addressed all aspects of his complaint and also to provide a further written response to Mr A which addressed all aspects of his complaint, including those relating to care and treatment provided by CAVUHB and WAST.

Mrs A complained to Aneurin Bevan University Health Board about care and treatment provided to her late husband, Mr A. Following receipt of the Health Board’s complaint response, Mrs A remained dissatisfied, as she considered that it did not address the issues she raised and created more questions than it answered. The Ombudsman found that the Health Board’s response did not address all of the concerns Mrs A raised, and did in fact raise further questions about the care provided to Mr A, including the disclosure that some of Mr A’s records were missing, which Mrs A was previously unaware of. The Ombudsman contacted the Health Board and in resolution of Mrs A’s complaint it agreed to, within 10 working days, offer her the opportunity to attend at a meeting to discuss her outstanding concerns. Within 20 working days of the offer of the meeting being made (if Mrs A declined the invitation) or the date of the meeting itself, it agreed to provide a further response to Mrs A, which addressed all of the outstanding concerns raised in respect of Mr A’s treatment.

Mrs B complained, on behalf of her brother Mr A, about unreasonable delays by Aneurin Bevan University Health Board (“the Health Board”) before undertaking Mr A’s treatment for colorectal cancer. Mrs B said that the Health Board failed to tell Mr A that his planned surgery had been cancelled and did not re-schedule the surgery until prompted by telephone calls and a complaint from the family. Mrs B also said that the Health Board failed to undertake Mr A’s surgery within an appropriate timeframe, causing progression of the disease and a less certain outcome. The Ombudsman found that the Heath Board failed to schedule surgery and only did so 5 weeks later after prompting by Mr A. This resulted in an avoidable delay that did not meet the National Pathway guidelines for colorectal cancer. This caused considerable trouble and distress to Mr A. The Ombudsman concluded that the care Mr A received, in terms of scheduling surgery, failed to meet an appropriate standard and upheld those aspects of the complaint. The Ombudsman did not uphold the complaint relating to the delay causing a less certain prognosis as evidence of this was unclear. The Ombudsman recommended that the Health Board should apologise to Mr A and Mrs B for the failings identified in surgery scheduling and delays caused. She also recommend that the Health Board should complete an audit of the current colorectal surgery scheduling process and controls. If not found to be robust, to put a plan in place to close any gaps identified. The Health Board agreed to implement these recommendations.

Ms A complained that Aneurin Bevan University Health Board had failed to provide her with a response to the complaint she submitted in September 2022. The Ombudsman decided that there had been a delay in the Health Board’s response which caused inconvenience and frustration for Ms A. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to apologise to Ms A and issue the complaint response within 3 weeks.

Mrs A complained about the care and treatment her late mother, Mrs B, received, after transfer from the Royal Gwent Hospital (“the First Hospital”), during an admission to Ysbyty Ystrad Fawr (“the Second Hospital”) between 19 August and 8 September 2020. She complained that the Welsh Government’s COVID-19 guidance about visiting Mrs B at the Second Hospital was not followed, Mrs B’s nutrition and medication during the final weeks of her life were not managed, there was a failure to have managed Mrs B’s deterioration and to provide appropriate and dignified end of life care. Mrs A also complained that Mrs B’s medical records were not accurately maintained. The Ombudsman found that the Health Board acted in accordance with guidance about access to the Second Hospital by visitors during the COVID-19 period. She found that Mrs B’s deterioration was managed in an appropriate and dignified manner and there were no significant shortcomings in the quality of Mrs B’s medical records. The Ombudsman found that, aside from one prescribing error (brought about by a lack of communication between the First and Second Hospital) which had not had any adverse clinical outcome, the management of Mrs B’s nutrition and medication was appropriate. She invited the Health Board to reflect on the failure to ensure adequate transfer of clinical information between the hospitals. The Health Board acknowledged this failure and has implemented an electronic handover document for patients, backed up by a hand over between ward teams. The Ombudsman did not uphold the complaints.

Mrs A complained about the care and treatment her late husband, Mr A, received from Aneurin Bevan University Health Board (“the Health Board”). Specifically, she complained about whether Mr A was appropriately reviewed by the Cardiology Department, including in relation to ensuring that his intensive medication regime was not having a detrimental effect on his internal organs (specifically his pancreas). Mrs A also complained about the care Mr A received at the Emergency Department (“ED”) and the decision not to admit him to the Intensive Care Unit (“ICU”) prior to his death from acute necrotising pancreatitis. The Ombudsman found that, although there were administrative oversights which resulted in two Cardiology review appointments not being undertaken, these appointments would not have identified the acute pancreatitis which ultimately caused Mr A’s death. The Ombudsman also found no evidence to suggest that Mr A’s medication regime contributed to the development of his pancreatitis and that additional monitoring of his pancreas was not necessary. The Ombudsman found that there was a delay in a doctor assessing Mr A in the ED, but that this was not clinically significant in terms of the eventual outcome. The investigation found that the clinical care Mr A received and the decisions taken not to escalate care to the ICU were appropriate. The complaints were not upheld.