Report Date


Case Against

Aneurin Bevan University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Mr L complained about the care provided to his late mother, Mrs M, when she was an inpatient in November 2019. Specifically, Mr L complained that the Health Board failed to monitor and treat Mrs M’s breathlessness properly; failed to provide her with adequate support to use the toilet; did not give enough consideration to meeting Mrs M’s religious and cultural needs; did not communicate effectively with Mrs M or her family about her care and did not take appropriate action to prepare Mrs M’s body following her death.

Although it could not be said with certainty that the outcome would have been different, the Ombudsman found that there were failings in the monitoring and treatment of Mrs M’s breathlessness. In particular, the investigation identified inadequate nursing monitoring, an amendment to the plan of care which was not supported by a chest X-ray and that a CT scan had not been carried out as planned for reasons which were unclear. The Ombudsman also found that the care plan for Mrs M’s toileting needs was inadequate and that there was a failure to meet her cultural or religious needs, for example, by failing to offer her the Halal menu. The Ombudsman also upheld the complaints about communication with Mrs M and her family; in particular, that insufficient assessment had been made of Mrs M’s communication needs when she had limited understanding of English. It was not enough to rely on family members who happened to be present to translate for her without an assessment of whether this was sufficient or appropriate. Finally, the Ombudsman partly upheld the complaint about the preparation of Mrs M’s body to the extent that a cannula was not removed.

The Ombudsman recommended that the Health Board should apologise to Mr L for the failings identified and pay financial redress of £5,000 in recognition of the impact these had on Mrs M and her family. He also recommended that relevant staff be reminded of the importance of regular monitoring, effective communication and of the need to make patients aware of the dietary options available. He also recommended that an audit of various nursing documentation on the ward in question should be carried out. The Ombudsman recommended that the Health Board take steps to raise awareness of its Translation Policy, the availability of translation services and that the report be shared with the Health Board’s Equalities Officer to consider whether further actions needed to be taken. Finally, he recommended that training that had been planned, but postponed due to the COVID-19 pandemic, on awareness of cultural and spiritual diversity should now be taken forward.