Aneurin Bevan University Health Board has been criticised for the care given to the man, Mr C (anonymised), in October 2016, after a complaint was received from Mrs B, his mother.

The investigation found that:

• Earlier referral, by the Podiatry Service, to a specialist team might have resulted in earlier treatment of his condition and might have prevented the need to amputate Mr C’s toe.

• Further steps should have been taken before Mr C was discharged, following his first hospital admission, and had these steps been taken Mr C’s care might have been managed differently.

• The investigation also found that Mr C was at increased risk of Deep Vein Thrombosis (DVT) / Pulmonary Embolism (PE), and that protection should have continued after he was discharged from his second hospital admission.

The Health Board has agreed to make a payment of £4,000 in recognition of the failings identified in the report and apologise in writing to the family of Mr C. Additionally, it has agreed to undertake a root cause analysis investigation of the death and put in place an action plan to prevent the situation happening again.

Commenting on the report, Nick Bennett, Public Services Ombudsman for Wales, said:

“The desperately sad outcome of this case may have been avoided had Mr C been treated in the correct manner.

“In particular, I am extremely concerned the patient was discharged early following his first hospital admission without full consideration of his condition and that on his second discharge from hospital he was not given appropriate protection against Deep Vein Thrombosis and a Pulmonary Embolism. This case further highlights the importance of thorough discharge procedures for all patients.

“Mr C was just 42 years old when he passed away and the effect of such a premature death on his family cannot be underestimated.”