Report Date


Case Against

Aneurin Bevan University Health Board


Adult Mental Health

Case Reference Number



Not Upheld

Mrs A complained about the care that her late father, Mr B, received following his admission to hospital. She complained that the decision to insert a catheter (a tube inserted into the bladder to allow urine to drain freely) and discharge him with it in place was not clinically appropriate. Mrs A also complained that there was a failure to consult with her or her brother (Mr C), who both held the authority to make decisions about Mr B’s health and welfare. The complaints were not upheld.

The investigation found that the decision to insert the catheter was clinically appropriate based upon treatment Mr B was receiving for sepsis and because of the outcome of fluid balance monitoring. It was also necessary to discharge Mr B with the catheter in place because of Mr B’s reduced mobility, his prolonged stay in hospital and his difficulty emptying his bladder.

The investigation also found that although the clinicians did not consult with Mrs A and Mr C, it was appropriate and reasonable to go ahead with catheterisation in Mr B’s best interests. This was because of the urgency of the situation in relation to sepsis, and because Mr B was not able to empty his bladder. Mr B was also showing signs of agitation. This improved following catheterisation.

The Ombudsman did identify some issues with the documentation. She has invited the Health Board to consider those issues and Mrs A’s request to create, if one is not already in place, a guidance document on consultation with family members who have the authority to make health and welfare decisions.