Report Date


Case Against

Aneurin Bevan University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Mr Y complained about the care his wife, Mrs Y, received following admission to hospital in January 2019 with a severe headache. Following a clear head scan, a decision was made to carry out an Epidural Blood Patch (“EBP”, a procedure commonly used to treat spinal headaches). 2 days later, Mrs Y’s condition deteriorated suddenly and investigations identified a brain haemorrhage; despite undergoing surgery, Mrs Y sadly died.

The Ombudsman concluded that:
• Mrs Y was appropriately assessed on admission and a diagnosis of Intracranial Hypotension (where there is an abnormally low pressure within the skull resulting in a headache) was within the bounds of acceptable clinical practice based on Mrs Y’s presenting symptoms and previous history of similar headaches.
• The consent for the EBP and the procedure itself was carried out within the bounds of acceptable clinical practice and in line with relevant guidelines; the haemorrhage Mrs Y was subsequently diagnosed with was not a recognised complication from an EBP procedure.
• Whilst it was unclear how long Mrs Y was lying down after the procedure as her positioning was not documented, even if she had been laying down for less than the recommended time, this would not have been a contributory factor to the haemorrhage she subsequently developed.
• There was no reason to request a medical review following the EBP as Mrs Y was noted to be reasonably comfortable the following day and Mrs Y received regular nursing reviews.

The Ombudsman did not uphold Mr Y’s complaints relating to Mrs Y’s clinical care.

However the Ombudsman found that the time taken by the Health Board to conclude its investigation into Mr Y’s complaint, and the use of medical terminology without clear explanations/suitable definitions within the investigation report amounted to maladministration and fell outside the requirements laid out in its policy for managing serious concerns (“the policy”). This was an injustice to Mr Y and this complaint was upheld. The Health Board agreed to apologise for these shortcomings and to highlight these issues as part of its review of the policy.