Report Date


Case Against

Aneurin Bevan University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Mrs X had a 20 year history of myasthenia gravis (muscle weakness that caused swallowing difficulties). On 6 November 2019 Mrs X was diagnosed with cancer of the tongue with no curative option. On 25 November she was taken by ambulance to the Royal Gwent Hospital (“the Hospital”) because of her swallowing issues. At the Hospital it was noted that Mrs X’s swallow was weaker, she had choking episodes and was unable to spit. Her blood pressure was slightly low but all her observations were within the normal range. Mrs X was advised to go home with a suction machine and she was discharged for a follow-up appointment at the Cancer Centre the next day. On 26 November Mrs X’s condition at home deteriorated, the out of hours GP (“OOHGP”) was called at 03:14. An OOHGP attended, Mrs X was afraid to sleep as she might choke, she was exhausted but not in pain. It was explained that both tongue cancer and myasthenia could obstruct the airway. She was advised to continue with suction as required and palliative Hyoscine patch (used to decrease saliva) until a palliative review later that day at 09:00. It was agreed to continue with this treatment until the palliative review. The OOHGP recognised Mrs X was terminally ill, but had not expected her to die that morning. Sadly, Mrs X died at 04:55.

Mrs Y complained about whether her late mother, Mrs X had an appropriate amount of support and care at home before her discharge, the treatment Mrs X received from the OOHGP and that the Health Board had not responded to her complaint about the OOH service.

The Ombudsman found that as Mrs X was managed at home with family support, the provision of a full care package did not have to be explored; this aspect of the complaint was not upheld. The Ombudsman also found that the OOH service Mrs X received was reasonable and this aspect of the was not upheld. The Ombudsman found that the Health Board should have included its investigations into the out of hours service in its complaint response. This aspect of the complaint was upheld.

The Health Board agreed to implement the Ombudsman’s recommendation and apologise to Mrs Y for this failure.