Report Date


Case Against

Aneurin Bevan University Health Board


Clinical treatment in hospital

Case Reference Number



Not Upheld

Mr X complained about the treatment his late mother, Mrs Y, received at the Royal Gwent Hospital in September 2020 following a stroke, in particular the administration of medication to reduce her blood pressure. Mrs Y’s condition deteriorated; it was concluded that she had suffered a further “devastating event” within the brainstem and she sadly died a few days later.

The Ombudsman found that Mrs Y had been given 3 different medications to reduce her blood pressure. Although one of them (a GTN infusion) was not indicated and should not have been given, and it would have been more appropriate to have delayed another medication until the following day, the deterioration in Mrs Y’s condition was not caused by a drop in her blood pressure and thus was not as a result of the medication she received. The Ombudsman also found there had been failings in record keeping. However, the service failure and administrative failings had not caused Mrs Y an injustice and, therefore, the Ombudsman did not uphold the complaint.