Report Date


Case Against

Aneurin Bevan University Health Board


Clinical treatment in hospital

Case Reference Number



Voluntary settlement

Mrs B complained about her late husband, Mr B’s treatment for cancer in hospital. She complained that Mr B developed a pressure sore due to the hospital’s failure to re-position him sufficiently, and that when the sore was treated with a specialist therapy dressing (“VAC therapy”), it was not appropriately maintained as staff were not trained to use it. She also complained that there was a delay in the Health Board realising Mr B developed sepsis, that Mr B did not receive daily physiotherapy during his time in hospital, that he was left without pain relief medication on 2 occasions, and that there was an unnecessary delay in discharging him home.

The investigation found that there were 2 occasions whereby Mr B’s pain relief medication was not refilled in a timely manner, 1 of which may have left him without pain relief for several hours. This complaint was therefore upheld as an injustice to Mr B, however it was noted that the Health Board had since implemented learning procedures to address this issue.

The investigation also found that while Mr B had 3 episodes of suspected sepsis, there was only evidence to suggest that there may have been a slight delay of just over 1 hour in treating the first instance, rather than the delay of several days Mrs B was concerned had been the case. This complaint was therefore partly upheld.

The investigation found that the evidence available suggested the pressure sore developed when Mr B was transferred to a specialist centre for chemotherapy treatment, and that after he was transferred back to the hospital the sore was treated appropriately. It found that while not all nurses were trained in using the specialist VAC therapy, it was monitored and changed sufficiently often, and there were specialist

staff available, even if not immediately accessible on the ward. The investigation found that due to the seriousness and location of the

pressure sore, Mr B’s several bouts of sepsis, and the later discovery that his cancer had spread, the original physiotherapy plan was not suitable, although this could possibly have been communicated better to Mr and Mrs B. Finally it found that the medical records reflected staff’s understanding of Mr B’s preference to return home and they were working to achieve this, but the treatment of the sore, his suspected sepsis, further cancer spread, number of specialists involved in his care, and issues in obtaining appropriate home care and equipment, meant it took some time before he could safely be discharged. These complaints were therefore not upheld.

The Ombudsman recommended that the Health Board apologise to Mrs B for the issues identified.