Report Date


Case Against

Aneurin Bevan University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Mr D complained that the care and treatment that his late mother in law, Mrs M, received following her transfer from the Royal Gwent Hospital (“the First Hospital”) to Ystrad Fawr Community Hospital (“the Second Hospital”) contributed to her sudden death some 2 days later from Hospital Acquired Pneumonia (“HAP”). Mr D complained that:

1.Antibiotics were discontinued prior to Mrs M’s transfer but were not re started despite blood test results indicating infection.

2.Mrs M’s fluid intake was insufficient and poorly monitored.

3.Mrs M was not adequately monitored by nurses and, though issued with a call-buzzer, was unsure of how to use it.

4.Communication with the family was poor and, on occasions, nurses were insensitive and unprofessional in tone and manner.

The Ombudsman upheld complaint 1 to the extent that Mrs M’s antibiotics were prematurely discontinued by the First Hospital (Mrs M had passed away by the time the need to restart them was determined by the Second Hospital). The Ombudsman also found that the reason why Mrs M did not respond to the antibiotics she initially received was not explored at the First Hospital and advice from microbiology was not sought. This represented a lost opportunity to control and stabilise Mrs M’s condition and, thereby, to improve her prognosis.

The Ombudsman upheld complaint 2 insofar as Mrs M was shown to be dehydrated on the morning that she passed away (though not before this). He also found that Mrs M’s fluid management was not specifically addressed in her care planning.
The Ombudsman did not uphold complaint 3. He found that the monitoring of Mrs M by nurses at the Second Hospital was of a good standard. The Ombudsman upheld complaint 4 but considered that the matter had been addressed appropriately by the Health Board and did not require further recommendations.

With regard to Mr D’s overarching complaint that these failings contributed to Mrs M’s sudden death, the Ombudsman found that, whilst failings of antibiotic management at the First Hospital probably allowed Mrs M’s chest infection to develop, this could not be definitively determined. Given Mrs M’s complex comorbidities, along with her age and frailty, it was not possible to say that a more sensitive antibiotic would have prevented her sudden death and/or led to her recovery. However, the Ombudsman found that the failings in Mrs M’s antibiotic management represented a lost opportunity to optimise her treatment and created uncertainty for the family surrounding the question of whether this would have led to a different outcome. To that extent, the complaint was upheld.

The Ombudsman recommended that the Health Board provides Mr D with a fulsome apology for the identified failings, together with a payment of £750. He also recommended that the report is shared with the Clinical and Nursing Director(s) responsible for the teams involved in Mrs M’s care at both hospitals and that clinicians are reminded:

•That it should be routine practice to obtain cultures of blood before commencing antibiotic therapy
•That patients should not be transferred for rehabilitation with incompletely treated pneumonia
•Of the importance of hydration and nutrition in care planning.