PSOW Individual Decisions

Mrs A complained about the outcome of two foot surgeries in March and June 2023, and the overall management of her care by Aneurin Bevan University Health Board. The Ombudsman recognised that there was a significant delay in the Health Board providing its response to Mrs A and that it failed to keep her appropriately updated. Mrs A had outstanding concerns that had not been addressed, including her belief that another patient’s records were placed on her file. The Ombudsman also noted a number of mistakes within the response. The Ombudsman sought and gained the Health Board’s agreement to, within 4 weeks, offer a payment of £250 to Mrs A for the complaints handling delays, apologise for the errors identified and place a note on the complaints file to correct these, and contact Mrs A to discuss her concern regarding her records. Then within 8 weeks, to investigate and provide a further response to Mrs A on the outstanding issues.

Ms A complained that Aneurin Bevan University Health Board failed to respond to a complaint submitted in July 2025. The Ombudsman found there had been a significant delay with the Health Board responding to Ms A’s complaint and that it failed to keep her regularly updated. This caused additional frustration and uncertainty for Ms A. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to write to Ms A, within 1 week, to apologise for the delay. It also agreed to issue its complaint response within 4 weeks, or issue an update letter if the complaint investigation is not completed.

Miss A complained about the care and treatment that she received during her inpatient admission at Royal Gwent Hospital (“the Hospital”). The investigation considered whether it was clinically appropriate for the prescribed cyclizine (an antihistamine and antiemetic drug for management of nausea) to be changed from intravenous to oral administration, for the prescribed dosage to be decreased and whether these aspects of the treatment plan were communicated appropriately to Miss A. It also considered if Miss A was afforded appropriate support from mental health services during the extended time that she was an inpatient, in particular, after she took an overdose on 23 January 2024. Finally, the investigation considered whether the Health Board appropriately reported on, recorded and investigated the overdose at the time of the incident. The investigation found that the prescribed dosage of cyclizine was consistent and the dosage and mode of administration were both in keeping with standard practice. Miss A was kept informed of the management plan but there was a missed opportunity to ascertain why she was intent on being prescribed the medication via IV; however, this did not amount to a service failure. There was no evidence within the clinical records that Miss A had requested psychiatric input, rather, it was recorded that support was appropriately offered at various points during admission, but declined by Miss A who had capacity to make that decision. The clinical actions taken in response to Miss A’s overdose were appropriate; however, the incident was not reported in line with expected process. The Health Board has, during the course of this investigation, retrospectively recorded the incident. I am satisfied that Miss A did not suffer an injustice as a result of this omission as she received appropriate care regardless of the failure to document the incident. Nevertheless, the Health Board has been invited to remind all staff within the Urology and Medical te

Mr C complained on behalf of his late mother, Mrs A, about the care and treatment she received from her GP Practice. The investigation considered whether the management of Mrs A’s back pain from February to July 2023 was clinically appropriate. Mr C also complained about the care and treatment Mrs A received from the Health Board. However, the Health Board chose not to investigate this complaint. The Ombudsman used her discretion to investigate the matter without the Health Board having provided a response. The investigation considered whether Mrs A’s care and treatment during her first admission on 31 March 2023 was clinically appropriate and whether there should have been a follow-up. The investigation also considered whether the management of referrals from Mrs A’s GP by the Health Board was appropriate between February 2023 and her second admission on 17 July 2023. The investigation found that the management of Mrs A’s back pain by the Practice did not reach an appropriate standard, as red flags that might have indicated Mrs A’s cancer were not identified. The Ombudsman upheld this complaint point. It also found that the care and treatment provided to Mrs A during her admission on 31 March was not clinically appropriate because she was not examined by the correct specialism and clinicians failed to consider an alternative diagnosis for her pain. The Ombudsman also upheld this complaint point. Finally, the investigation found that the Health Board’s management of referrals from Mrs A’s GP was appropriate and so this point was not upheld. The Practice accepted the Ombudsman’s recommendations and agreed to apologise to Mr C and his family, and provide a copy of the Red Flags Guidance to all its clinicians. The Health Board accepted the Ombudsman’s recommendations and agreed to apologise to Mr C and his family, to review the case for points of learning, to remind relevant clinical staff of guidance around intimate examinations, and to make improvements to its record

Mr C complained on behalf of his late mother, Mrs A, about the care and treatment she received from her GP Practice. The investigation considered whether the management of Mrs A’s back pain from February to July 2023 was clinically appropriate. Mr C also complained about the care and treatment Mrs A received from the Health Board. However, the Health Board chose not to investigate this complaint. The Ombudsman used her discretion to investigate the matter without the Health Board having provided a response. The investigation considered whether Mrs A’s care and treatment during her first admission on 31 March 2023 was clinically appropriate and whether there should have been a follow-up. The investigation also considered whether the management of referrals from Mrs A’s GP by the Health Board was appropriate between February 2023 and her second admission on 17 July 2023. The investigation found that the management of Mrs A’s back pain by the Practice did not reach an appropriate standard, as red flags that might have indicated Mrs A’s cancer were not identified. The Ombudsman upheld this complaint point. It also found that the care and treatment provided to Mrs A during her admission on 31 March was not clinically appropriate because she was not examined by the correct specialism and clinicians failed to consider an alternative diagnosis for her pain. The Ombudsman also upheld this complaint point. Finally, the investigation found that the Health Board’s management of referrals from Mrs A’s GP was appropriate and so this point was not upheld. The Practice accepted the Ombudsman’s recommendations and agreed to apologise to Mr C and his family, and provide a copy of the Red Flags Guidance to all its clinicians. The Health Board accepted the Ombudsman’s recommendations and agreed to apologise to Mr C and his family, to review the case for points of learning, to remind relevant clinical staff of guidance around intimate examinations, and to make improvements to its record

Mr A complained that Aneurin Bevan University Health Board had failed to respond to his complaint and it had failed to keep him updated. The Ombudsman found that the Health Board had not responded to Mr A’s complaint and it had failed to keep him updated. She said this caused uncertainty and frustration for Mr A. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to, within 3 weeks, offer an apology and explanation, issue its response and offer £150 financial redress in recognition of the delays and lack of updates.

Mrs A complained that Aneurin Bevan University Health Board failed to issue a response to her complaint, made in November 2024, regarding the care and treatment provided to her. The Ombudsman found that the Health Board had not provided Mrs A with a complaint response and that this caused uncertainty and frustration for Mrs A. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to write to Mrs A with an apology and explanation for the delay, offer to pay £150 in recognition of the delay and to issue a complaint response. The Health Board agreed to do this within 1 month of the Ombudsman’s decision.

Ms A complained that Aneurin Bevan University Health Board (“the Health Board”) did not follow appropriate guidelines when making its decision not to progress a retrospective Continuing Health Care (“CHC”) claim to an Independent Review Panel. The Ombudsman was concerned that whilst the Health Board had loosely followed the requirements of the CHC National Framework, the Independent Chair’s rationale for not moving to an Independent Review Panel was generic, and did not specifically address concerns raised. The Independent Chair did not address a legitimate concern regarding the date of CHC eligibility. The Ombudsman sought and gained the Health Board’s agreement to, within 1 month, refer the case to a different Independent Chair to reconsider whether an Independent Review Panel is warranted, with the new Independent Chair addressing the specific point about the date of CHC eligibility. The Ombudsman also gained agreement for the Health Board to confirm that all future Independent Chair decisions will be accompanied with case specific rationale, and that evidence of this process would be provided within 2 months.

Mr J complained that a joint risk assessment undertaken by the Council and the Health Board and provided to a Supported Housing Provider (SHP) was missing key information about his son’s needs. This led to him being placed in what Mr J believed to be an unsuitable placement. Mr J also complained that the Council was not willing to carry out its own investigation into his concerns about the risk assessment when a proposed joint investigation with the Health Board did not progress. The investigation against the Council identified failings around documentation and how aspects of the care co-ordinator role had been carried out. However, the Ombudsman concluded that, prior to the placement, the SHP was provided with sufficient key information about the needs of Mr J’s son by the Health Board who was jointly involved in commissioning the placement. In relation to the Council and the Health Board, this part of Mr J’s complaint was not upheld. The Ombudsman found that an opportunity for the Council to identify and learn lessons from Mr J’s complaint was missed by its decision not to carry out its own investigation. The injustice for Mr J was that he had to complain further in order to obtain answers. This part of Mr J’s complaint was upheld. The recommendations to the Council included apologising to Mr J and carrying out an audit across the Community Mental Health Teams in order to satisfy itself that the requirements of the care co-ordinator role, as well as wider processes and systems, are being met. As part of the audit process the Council was asked to engage with the Health Board as appropriate. The Health Board was invited to engage with the Council around the audit recommendation set out above, as this would also provide an opportunity to ensure that any wider points of learning around systems and processes in relation to jointly commissioned care are maximised.

Mrs B complained that Aneurin Bevan University Health Board failed to provide a response to her complaint about her late mother, which she made to it, in June 2025. The Ombudsman found that the Health Board had failed to provide regular and meaningful updates and had not issued a complaint response. She said that this caused frustration and uncertainty to Mrs B. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to write to Mrs B with an apology and explanation for the delay, provide a further apology for the lack of updates, offer Mrs B £75 redress and issue a complaint response within 4 weeks.

Mr A complained about the care and treatment provided to him by the Health Board for his various health conditions. Mr A also complained about the Health Board breaching the Armed Forces Covenant duty. The Ombudsman found that the Health Board had not provided a response to the complaint Mr A made in May 2025 and when he raised further concerns, they were not acknowledged or responded to as a complaint. This caused additional frustration and uncertainty for Mr A. The Ombudsman decided to settle the complaint without an investigation. The Health Board agreed the Ombudsman’s proposal to provide a formal response to the complaint Mr A made in May 2025 within 4 weeks, and to apologise for the delay. The Health Board also agreed to provide written acknowledgement of Mr A’s further concerns within 1 week and to make all reasonable attempts to agree the parameters of the further complaint with Mr A within 4 weeks and to provide written confirmation that it will respond to the agreed complaint under Putting Things Right.

Mrs A complained that Aneurin Bevan University Health Board failed to respond to the complaint she submitted in July 2025. The Ombudsman found that the Health Board had failed to provide Mrs A with a formal complaint response. The Ombudsman said this caused uncertainty and frustration for Mrs A and decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to, within 4 weeks, issue the complaint response, apologise for the delay and explain why this happened.

Dr B complained that Aneurin Bevan University Health Board failed to issue a response to her complaint, which she submitted in April 2025, regarding the care and treatment provided to her late brother. The Ombudsman found that the Health Board had failed to issue a complaint response. She said this caused frustration and uncertainty to Dr B and 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 Dr B for the delay, issue a complaint response, and offer a redress payment of £150 in recognition of the delays she has experienced.

Mr A complained that Aneurin Bevan University Health Board improperly removed him from its ENT waiting list, stating that he had not contacted it when he had. The Ombudsman found that Mr A had followed the advice in the Health Board’s letter and had emailed it regarding an ENT appointment. Despite this, the Health Board had incorrectly removed Mr A from the ENT waiting list. The Ombudsman said this caused Mr A uncertainty and frustration and she decided to settle the complaint without a formal investigation. The Ombudsman sought and gained the Health Board’s agreement to apologise to Mr A for incorrectly removing him from the waiting list, to confirm in writing to Mr A that he had been reinstated on the waiting list in the same position he would have been in had he not been incorrectly removed, and to explain to Mr A what went wrong within 2 weeks.

Ms B complained about the care and treatment she received from Aneurin Bevan University Health Board in respect of its failure to examine her and delay in diagnosing a patella tendon rupture. The Ombudsman decided that the care and treatment provided was reasonable, and the Health Board’s complaint response was also reasonable. However, it was noted that Ms B had written to the Health Board again following receipt of the complaint response, and she had not received a further response. Whilst the Ombudsman considered that the Health Board had provided a reasonable response initially, it should have responded to Ms B to advise of this. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to, within 2 weeks, apologise to Ms B for not providing a response to her further letter.

We investigated a complaint from Mr A about his grandmother, Mrs B’s, hospital care in January 2024. The investigation specifically focused on whether the accepted lack of observations following Mrs B’s admission to hospital significantly impacted her condition, and whether communication with Mr A, his father (Mr C) and his grandfather (Mr F) by staff at the Hospital was appropriate, prior to, and following, the death of Mrs B. The investigation found that Mrs B received an appropriate level of clinical care given the challenges of treating her in light of the presence of multiple health conditions. However, there was a lack of action or escalation of care when her NEWS (a system to identify deterioration in a patient) was raised, which was contrary to expected practice. This was a service failure. However, the lack of observations/escalation did not significantly impact on Mrs B’s condition and did not contribute to her deterioration or death. This complaint was not upheld. The investigation found that communication with Mr A, Mr C and Mr F during Mrs B’s admission fell short of expected standards. The standard of communication following Mrs B’s death was also of concern. Despite telling Mr A in its complaint response that Mrs B expressed a preference for her sister to be contacted as opposed to her husband (who was the documented next of kin) and son, there were no corresponding entries in Mrs B’s records to support this, which was contrary to expected practice. This lack of contemporaneous records was contrary to the requirements of expected nursing standards. This amounted to maladministration and meant there was an inappropriate delay in informing Mr A, Mr C and Mr F about her poor prognosis and death. As a result, it is likely that they missed an opportunity to see Mrs B before she died. This was an injustice and this complaint was upheld. The Health Board agreed to apologise to the family for the serious communication shortcomings and to acknowledge the impac

Miss A complained about the care and treatment that her mother, C, received from the Health Board prior to her death. The Ombudsman considered that, as the complaint had been made prior to the death of C and HM Coroner’s Inquest, the Health Board had not considered Miss A’s specific concerns relating to her mother’s death. The Ombudsman sought and gained the Health Board’s agreement to, within 4 weeks, reconsider the care and treatment provided to C in light of her death, and the findings of HM Coroner, and provide a response to Miss A which reconsiders her original questions, and her view that the failure to correctly assess C resulted in her death.

Mrs A complained that Aneurin Bevan University Health Board failed to respond to her letter dated 15 November 2025 in which she was seeking clarification on the complaint response she had received. The Ombudsman found that the Health Board failed to respond to Mrs A. The Ombudsman said this caused additional frustration and uncertainty for Mrs A and decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to, within 2 weeks, write to Mrs A with a response to her letter which should also include an apology for not responding.

Ms A complained that Aneurin Bevan University Health Board had failed to respond to her complaint or update her regarding the care she received. The Ombudsman found that Ms A had complained to the Health Board 12 months ago and had still not received a formal complaint response. The Ombudsman considered that this caused Ms A to be left with unanswered questions and decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to issue a full complaint response which includes explaining the reasons and apologising for the delay to Ms A within 4 weeks.

Ms X complained that the Practice refused her request for a home visit to carry out a blood test. She stated that the Practice, failed to take into account how her mental health limited her ability to leave her home and, as a result, did not make reasonable adjustments for her needs. The Ombudsman found that Ms X’s blood test was routine and that she could reasonably attend at a later date. The Ombudsman was concerned to note that after Ms X disclosed her mental health difficulties and inability to leave her home, the Practice did not consider whether she would be placed at a substantial disadvantage or explore whether any reasonable adjustments were required. Additionally, the Practice’s claim that community nurses only visit patients who are ‘housebound’ was inconsistent with information published on its website. The Ombudsman decided to settle the complaint without carrying out a formal investigation. The Ombudsman sought and obtained the Practice agreement to, within 4 weeks: (1) remind staff that patients may be referred to a community nurse if they are unable to leave their home; and (2) review Ms X’s concerns to determine whether she would be placed at a substantial disadvantage and to explore whether any reasonable adjustments are required to reduce any barriers to her access to services.

Miss C complained about the care and treatment her father, Mr A, received from Aneurin Bevan University Health Board. Specifically, the investigation considered whether Mr A’s discharge from Yysbyty Ystrad Fawr on 3 January 2024 was appropriate and whether referral to mental health or psychiatric services should have taken place sooner. The Ombudsman found that Mr A’s discharge from the hospital was not reasonable or appropriate and was instead premature and inadequately planned. Furthermore, the investigation found that mental health/psychiatric input should have been requested before discharge. This was an injustice to Mr A and his family. The Ombudsman upheld both complaint points. The Health Board accepted the Ombudsman’s recommendations. This included an apology and an offer of financial redress for £1000 to Miss C and to share the report with relevant clinicians who provided care and with the Health Board’s Quality and Safety Committee. The Health Board agreed to provide evidence that training on mental capacity assessment and deprivation of liberty safeguards had been implemented. It also agreed to implement training and a number of service improvements around discharge planning processes aimed at addressing the causes of the failings in this case. Finally, it agreed to carry out an audit of capacity and depravation of liberty safeguarding assessments completed within the previous year and to address any failings identified as a result.

Mrs A complained about the care and treatment provided to her late husband, Mr B, in relation to a large bowel obstruction and sigmoid stricture. Following advice at an outpatient appointment in April 2024, Mr B opted for further investigations, rather than surgery. By the next appointment, his health had declined to the extent he was no longer fit for surgery. Mrs A said that, despite worsening symptoms, Mr B was not admitted to hospital for nutritional support, monitoring, or timely surgery. Mr B sadly passed away following an emergency admission and surgery in September 2024. Mrs A was dissatisfied with the Health Board’s complaint response. The Health Board was unable to provide records relating to the relevant outpatient appointment. The Ombudsman found that this raised concerns about the Health Board’s record-keeping. As a result, if the Ombudsman were to investigate Mrs A’s complaint, it would be difficult to establish with any certainty what was discussed in order to decide whether appropriate advice was given. This caused uncertainty and an injustice for Mrs A. The Ombudsman decided to settle the complaint without investigation. The Health Board agreed to, within 4 weeks, provide Mrs A with a written apology for the lack of clinical records in relation the relevant consultation and the fact that this has prevented the Ombudsman investigating the matter. It also agreed to, within 4 weeks, provide Mrs A with a further complaint response setting out the learning points identified and the action taken as a result.

Mrs B complained that Aneurin Bevan University Health Board failed to issue a response to her complaint, which she made to it in May 2025. The Ombudsman found that the Health Board had failed to issue a complaint response. She said this caused frustration and uncertainty to Mrs B. 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 B for the delay, offer a redress payment of £75 in recognition of her time and trouble in making her complaint to the Ombudsman, and provide a complaint response within 4 weeks.

We investigated Mr A’s complaint against a GP Practice in the area of Aneurin Bevan University Health Board (“the Practice”) that 2 safeguarding referrals made by the Practice to Social Services were not appropriate. The investigation found that both referrals were appropriate and the complaint was not upheld. The decision to make the first referral was appropriate. Even though there was no substantial new accusation contained in the second referral, safeguarding guidance is clear that this should not deter a professional from making a further referral if concerns continue.

Mr A complained that the Health Board failed to respond to his complaint. The Ombudsman found that the Health Board had not issued a response to the concerns raised by Mr A and this caused frustration and uncertainty for Mr A. The Ombudsman sought and gained the Health Board’s agreement to provide an apology, an explanation for the delay in responding and to issue a comprehensive complaint response to Mr A within one month.