Report Date


Case Against

Aneurin Bevan University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Mrs X complained about the care and treatment provided to her late husband Mr X, by Aneurin Bevan University Health Board (“the Health Board”). She complained that the Health Board failed to diagnose Mr X’s mesothelioma (a type of cancer that develops in the lining that covers the outer surface of some of the body’s organs), failed to communicate with them about the investigations undertaken and a probable diagnosis, failed to meet Mr X’s nutritional needs and failed to provide a good standard of nursing care. Mrs X also complained that the Health Board handled her complaint poorly and that its response contained inaccuracies and did not address her concerns.

The investigation found that, whilst the Health Board diagnosed Mr X’s mesothelioma 2 months after his death, the sequential approach taken to conduct investigations caused ongoing and unacceptable delays in establishing a probable diagnosis. Had Mr X’s diagnostic laparoscopy been completed sooner, it is likely that his diagnosis could have been confirmed prior to his death. Whilst an earlier diagnosis would not have affected the outcome for Mr X, it could have afforded Mr and Mrs X time to come to terms with the prognosis and led to the identification of a clear pathway for palliative care. This was an injustice to them. The Ombudsman considered that this failure impacted on Mr X’s rights as an individual and on both his and Mrs X’s rights as part of wider family life.

The investigation found that there was regular communication with Mr and Mrs X but there appeared to be a lack of conviction in relation to Mr X’s probable diagnosis. The uncertainty caused was an injustice to Mr and Mrs X. The investigation also found that nasogastric feeding would not have been considered had Mr X’s diagnosis been prompt and definitive. The use of nasogastric feeding was undignified and painful for Mr X and for Mrs X to witness, which was an injustice to them. This may also have impacted their human rights.

The investigation did not find that the Health Board fail to provide a good standard of nursing care in terms of personal care and skin care. However, the investigation did find serious failings in nursing record keeping in terms of food and input/output charts – whilst these failings were unlikely to have changed the outcome it caused uncertainty for Mr and Mrs X, which was an injustice to them.

The investigation found that the Health Board failed to keep Mrs X and her Advocate updated, wrongly gave them the impression that their response was imminent on 2 occasions, and failed to respond to additional questions from Mrs X. It’s response also included inaccuracies. These failings compounded Mrs X’s distress and bringing her complaint to the Ombudsman caused an inconvenience which were both an injustice to her.

Finally, the Health Board failed to comment on whether it had considered Mr X’s human rights and his right to dignified care. The Ombudsman considered this a great concern.

The Health Board agreed, within 1 month of the date of the final report, to provide a written apology, make a payment of £250 in recognition of poor complaint handling, share the report with relevant clinicians and its Equalities Lead and remind staff about the importance of good record keeping. It also agreed, within 3 months of the date of the final report, to review how patients with suspected cancer, identified outside of the standard urgent suspected cancer pathway, are managed to ensure they subsequently follow the urgent suspected cancer pathway towards a timely diagnosis, and take action to address any improvements identified. It also agreed to conduct random sampling audits of nursing records.