Report Date


Case Against

Aneurin Bevan University Health Board


Admissions/discharge and transfer procedures

Case Reference Number



Upheld in whole or in part

Ms X complained about her discharge from hospital in May 2020, specifically that she was not fit to be discharged and that it was not appropriate to move her to [Y] Care Home. Ms X was re-admitted to hospital just a day after her discharge.

The Ombudsman found that Ms X was not fit for discharge – she was in great pain, was frail and her mobility and her ability to carry out activities of daily living were limited; she was also having dialysis 3 times per week. The Health Board had given Ms X only 2 options – to move to the Care Home, despite her expressed wish not to do so, or to go home with an inadequate package of care. The Ombudsman found that the Health Board did not satisfy itself that the Care Home could meet Ms X’s needs; it was not appropriate to discharge her to a care home which could not meet her needs and against her wishes. She upheld the complaint.
The Ombudsman recommended that the Health Board apologise to Ms X for the failings identified and offer her a redress payment of £500 in recognition of the distress caused. She also recommended the Health Board take action to remind staff of the importance of carrying out discharge assessments, involving patients in discharge decisions and ensuring the discharge destination is suitable. The Health Board agreed to implement the recommendations.