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 that the Health Board failed to diagnose her husband’s (“Mr X”) sarcoma(sarcomas are a group of rare cancers affecting the tissues that connect, support and surround other body structures and organs) during his visit to the Emergency Department (“ED”) on 2 January 2018, inappropriately discharged Mr X on14 February, failed to action Mr X’s referral appropriately after biopsies were taken on 14 February, failed to expedite Mr X’s physiotherapy assessment and failed to respond to her complaint in a timely manner.
The Ombudsman found that Mr X’s management in ED was reasonable but that more could have been done to assess the likelihood of a recurrence of his Hodgkin’s Lymphoma. He found that the Health Board failed to follow its own discharge policy when Mr X returned home and more should have been done to involve Mrs X in the planning. The Ombudsman also found that poor record keeping meant it was impossible to reconcile Mrs X’s account of her husband’s physiotherapy treatment with what the records said. These aspects of the complaint were upheld. The Ombudsman did not uphold Mrs X’s complaint regarding Mr X’s referral following biopsy as he was satisfied that the Health Board took appropriate action to ensure the referral was prioritised as urgent. Finally, the Ombudsman was satisfied that Mrs X’s complaint was complex and that the Covid-19 pandemic had an adverse impact on its complaint handling capacity, which could not reasonably have been predicted. This aspect of the complaint was not upheld.
The Health Board agreed to implement the Ombudsman’s recommendations within 1 month, to apologise to Mrs X for the failings identified, makes a redress payment of £250 for the uncertainty and distressed caused and reminds staff of the importance of considering recurrences of Hodgkin’s Lymphoma in patients who are in remission. Within 3 months, the Health Board should share the report with relevant clinical staff and carry out an audit of physiotherapy records to monitor for accuracy.