Report Date


Case Against

Aneurin Bevan University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Mrs D complained about the care and treatment that her late mother, Mrs P, received at Ystrad Fawr Community Hospital during the weeks leading up to her death on 3 March 2020. Mrs D complained that, during February 2020, clinicians:

1.Failed to appropriately respond to Mrs P’s erratic blood-sugar levels and were slow to review and modify her diabetic care and treatment.

2.Failed to associate Mrs P’s elevated blood sugar levels with the possibility of systemic infection and to investigate this possibility in a timely manner.

3.Failed to prevent Mrs P from developing a grade 2 pressure ulcer.

4.Were slow to respond to Mrs P’s rapid deterioration and failed to formally initiate and to involve the family in Mrs P’s end-of-life/palliative care.

The Ombudsman partially upheld complaint 1. He found that there were occasions on which capillary blood glucose (CBG) levels were missed or delayed; that 2 doses of insulin were not given; that ketone levels were not always recorded and that, on one occasion, physicians inappropriately declined to conduct a review. Whilst these shortcomings did not result in any significant, clinically adverse consequence, Mrs P’s CBG levels were made more difficult to control and there was, on occasions, a lack of attention to detail in the management of her diabetic care.

The Ombudsman upheld complaint 2 to the specific extent that clinicians did not follow up a Urologist’s suggestion that Mrs P’s bladder emptying problems (and the risk of infection posed by residual or retained urine) should be monitored with further bladder scans. Whilst there was no evidence to suggest that the infection that Mrs P did develop was related to the incomplete emptying of her bladder, the uncertainty surrounding this (and whether an opportunity to treat an infection at an earlier stage might have been lost) was avoidable. This will remain a source of distress to Mrs D.

The Ombudsman did not uphold complaints 3 and 4. He found that Mrs P’s development of a pressure ulcer was not the result of any failure of care but was rather associated with the multiple factors involved in her deteriorating condition. He also found that the records indicated that clinicians took appropriate steps to ensure the family was kept informed of Mrs P’s deterioration and that they had understood the fact that Mrs P was receiving end-of-life care.

The Health Board agreed to:

•Provide Mrs D with a written apology for the failings identified in the report and make a payment of £250 to her in recognition of the inconvenience and trouble to which she was put in pursuing her complaint to the Ombudsman.

•Share the report with the Medical Director and Director of Nursing and confirm that physicians are reminded of the importance of conducting reviews and identifying and recording bladder-emptying problems in investigating and treating infections; and that nurses undergo revision of the care of the diabetic patient and in particular the procedure for obtaining and recording CBG readings.