Report Date


Case Against

Aneurin Bevan University Health Board


Clinical treatment in hospital

Case Reference Number



Voluntary settlement

Mx A was diagnosed with Nance Horan Syndrome (a rare genetic disorder), which causes a number of complications with communication including slurred speech as well as mobility issues. Mx A complained about the care and treatment they received in the Emergency Department (“the ED”) at Royal Gwent Hospital (“the Hospital”) in 2020. They felt that they were discriminated against because of their disability. They said that the Health Board failed to adequately address the ED nursing staff’s behaviour in May and July 2020 and the Lead Nurse for High Impact Service (“the Lead Nurse”) did not contact them as she said she would to devise a specific care plan should Mx A attend the ED again. Finally, Mx A complained about the robustness of the Health Board’s complaint handling.

The Ombudsman was satisfied that broadly the medical/clinical care provided to Mx A was reasonable and appropriate. However, the Ombudsman identified areas where Mx A’s care could have been better and more effective than it was, for example, around pain assessment and management and the prompter introduction of a personalised care plan given that Mx A were a frequent attender to the ED. The Ombudsman’s investigation also found that some of the clinical entries in Mx A’s clinical records contained comments which were unhelpful and might have led to an adverse inference regarding the basis on which she was obtaining treatment. The Ombudsman was critical of the 9 months delay between the Lead Nurse’s initial contact and the completion of the care plan, especially given Mx A’s vulnerability and their continued anxiety when they needed to attend the ED. Administratively, the Ombudsman found shortcomings in the Health Board’s complaint response as it did not address issues around clinical documentation or the delays in creating a person-centred care plan and providing Mx A with a timely response. The Ombudsman found Mx A had been caused an injustice as a result of the failings and their complaints were upheld.

The Ombudsman recommended that the Health Board apologise to Mx A for the failings identified by the investigation and pay Mx A £300 redress for the distress caused which also extended to the delays in complaint handling and putting in place a care plan. The Health Board was also asked to arrange training for the ED staff on Nance Horan Syndrome and how mini strokes/strokes can affect patients’ behaviour and presentation. Finally, if the Health Board had not already done so, it was asked to provide Equality and Diversity training workshops to all ED staff which should include the use of inclusive language.