Report Date


Case Against

Aneurin Bevan University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Mrs B complained about care provided to her mother, Mrs C, by the Health Board following her admission to the Royal Gwent Hospital in October 2020. Specifically, she was concerned that:
a) The Health Board failed to appropriately assess and treat Mrs C’s continence needs in order to enable a timely discharge.
b) There was a failure by medical staff to involve Mrs B, holder of a Lasting Power of Attorney, in discussions about Mrs C’s medical needs as required by the Health Board’s dementia policy.
c) There was a failure to provide appropriate care to Mrs C after she was placed on an end-of-life care pathway.
The investigation found that the Health Board did not miss opportunities to discharge Mrs C. However, the first part of the complaint was upheld to the limited extent that there was a failure to consider how to manage Mrs C’s constipation and provide earlier treatment that might have eased her symptoms. The investigation found that there had been a failure to communicate appropriately with Mrs B about Mrs C’s condition after 5 November which negatively affected the care provided. Accordingly, that part of the complaint was also upheld. The Ombudsman did not uphold the complaint about Mrs C’s end of life care, because the investigation found that the care provided was appropriate and in keeping with relevant guidance.

The Ombudsman recommended that the Health Board should apologise to Mrs B for its failings and provide reminders to relevant nursing staff of expected standards in relation to dementia and hydration care. The Ombudsman also recommended that the Health Board should remind relevant doctors of the importance of appropriately managing bowel health and of communicating well with the families of patients with dementia.