Report Date


Case Against

Aneurin Bevan University Health Board


Admissions/discharge and transfer procedures

Case Reference Number



Upheld in whole or in part

Mrs A complained about her late husband, Mr A’s care at the Royal Gwent Hospital’s Medical Assessment Unit (MAU) including the investigations undertaken, the treatment of his chest infection and the adequacy and appropriateness of his discharge from the MAU as well as poor communication. She was also dissatisfied with the robustness of the Health Board’s complaint response. Mr A had recently been diagnosed with a brain tumour, which affected his gait and balance and caused increasing seizures.
The Ombudsman’s investigation concluded that Mr A’s discharge was not safe, seamless or effective and was compounded by poor documentation and record-keeping, especially when it came to the nursing records. The failure to carry out key assessments properly, such as those relating to falls, coupled with the Discharge policy not being adhered to, meant that an occupational therapist/physiotherapy referral and assessment was also not completed. He also identified that communication was not as effective as it should have been. He found that the failings had caused Mr and Mrs A an injustice and the Ombudsman upheld these parts of Mrs A’s complaint.
The Ombudsman found no evidence that Mr A had a chest infection and did not uphold this part of Mrs A’s complaint.

In terms of complaint handling, the Ombudsman found that the Health Board’s complaint response did not fully acknowledge or recognise the extent of the failings identified in the report and was insufficiently robust. As it impacted both on Mrs A’s confidence in the complaint handling process and the time left with her husband, it was found that Mrs A had suffered an injustice and this aspect of her complaint was upheld.

The Ombudsman’s recommendations included the Health Board apologising to Mrs A, developing an action plan to ensure that the MAU adheres to its Discharge Policy, improving referrals to the physiotherapy service and communicating the DVLA requirements to patients where their driving is impaired by their medical condition/medication.