Report Date


Case Against

Aneurin Bevan University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Miss D complained about the care and treatment her father, Mr E, received following his admission to the Royal Gwent Hospital on 11 October 2020, and during his time at Ysbyty Ystrad Fawr until his death on 12 December 2020. In particular, Miss D was unhappy with the prescription and dosage of risperidone (an antipsychotic drug to help with symptoms of dementia) Mr E received, the amount of time Mr E spent on the COVID-19 ward, poor communication with Miss D in relation to Mr E having a fall and not receiving regular updates on Mr E’s condition, not being informed Mr E had pneumonia and the standard of nursing care especially in relation to Mr E’s personal hygiene and his fluid intake.

The Ombudsman’s investigation found that Mr E’s dosage of risperidone was appropriately managed, that he only remained on a COVID-19 ward while he returned a positive swab and he was moved the moment his test was negative, that communication between staff and Miss D was appropriate, and that Miss D was informed Mr E had a chest infection and that he was on a course of antibiotics. The Ombudsman did not uphold these elements of the complaint.

However, the Ombudsman concluded that the nursing care Mr E received was inconsistent and that relevant national guidance was not always adhered to. Assessments were not carried out and an individualised plan of care was not completed upon his admission. Mr E’s fluid intake was recorded but either intermittently or in no detail. These shortcomings amounted to service failures that caused Mr E the injustice of having nursing care that did not meet the required national guidelines. This aspect of the complaint was upheld.

The Ombudsman recommended that the Health Board should apologise to Miss D for the service failures identified, and that it should share the report with the nursing staff involved in Mr E’s care to discuss the identified failings and to update the Ombudsman’s office with the improvements it plans to implement as a result. The Health Board agreed to the recommendations.