Report Date

09/02/2021

Case Against

Aneurin Bevan University Health Board

Subject

Clinical treatment in hospital

Case Reference Number

202003520

Outcome

Not Upheld

Mrs X complained that the nursing staff at Aneurin Bevan University Health Board (“the Health Board”) failed to properly monitor her blood loss during a postpartum haemorrhage. The Ombudsman did not uphold the complaint.

The investigation found that Mrs X’s blood loss was properly monitored and that the Health Board’s response to her blood loss was rapid and appropriate. There was a failure to record Mrs X’s observations at the required intervals, however, this did not impact upon Mrs X’s overall care and did not cause an injustice to Mrs X.

The standard of communication between the Health Board’s staff and Mrs X was below the expected standard. However, following the event, the Health Board developed an information sheet for patients to begiven alongside verbal communication. This was an example of good practice which should prevent a similar future occurrence.