Report Date


Case Against

Aneurin Bevan University Health Board


Clinical treatment in hospital

Case Reference Number



Early resolution

Mrs A raised a number of concerns on behalf of her late father, Mr B, about the care and treatment provided by the Health Board in September 2021 following his cancer diagnosis.

Whilst some of Mrs A’s concerns did not meet the requirements for an investigation by the Ombudsman, the Health Board had not provided a robust response to 2 issues. These were that the Health Board had:

• arranged an ambulance transfer between hospital sites contrary to Mr B’s wishes during which he was unnecessarily immobilised on an inflatable stretcher causing confusion and distress

• initiated a poorly timed, insensitive discussion with Mr B about whether he wanted to receive cardiopulmonary resuscitation (CPR) in the event of cardiac arrest and did not take his views into account.

The Ombudsman contacted the Health Board and, in order to settle the complaint, it agreed provide a more considered response to the first issue and to share Mrs A’s complaint with the doctor who spoke to Mr B about CPR to provide an opportunity for learning and reflective practice.