Report Date


Case Against

Aneurin Bevan University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Mrs P complained that multiple failings in the care and treatment provided to her late father, Mr T, by Aneurin Bevan University Health Board at the Royal Gwent Hospital and St Woolos Hospital, resulted in him suffering avoidable pain and distress, hastened his deterioration, and led ultimately and avoidably, to his death from sepsis. The investigation considered Mrs P’s specific complaints that clinicians:
• Failed to respond with sufficient urgency (and in accordance with established clinical guidance) to the possibility that Mr T had suffered an ischaemic stroke.
• Failed to competently catheterise Mr T resulting in him suffering extreme pain, discomfort and a urinary tract injury which led to infection.
• Failed to implement the Health Board’s sepsis protocol in a timely manner.
• Failed on numerous occasions, to adequately document and/or act upon significant clinical information in accordance with established procedure (in relation to NEWS charting and escalation, hydration, pain assessment, blood-test results, medication omissions and catheter monitoring).
• Failed to competently manage and record the prescription and administration of Mr T’s antibiotic medication.
The investigation also considered Mrs P’s complaint about the Health Board’s handling of her complaint and the protracted delay in providing a formal response.

The investigation found that the care Mr T received for his suspected stroke was appropriate, timely and in keeping with relevant guidance. Accordingly, the Ombudsman did not uphold that complaint. The investigation found, on balance, that there was a failure to catheterise Mr T appropriately and that this had caused him avoidable pain and distress. For that reason that complaint was upheld. The investigation found that there was a failure to carry out sepsis screening on 4 June which would, at the very least, have provided reassurance to Mr T that he was receiving appropriate care. As a result, that complaint was upheld. The investigation also found that there were a series of failures to carry out required observations during Mr T’s admission and that this was part of a pattern of poor nursing care which resulted in avoidable pain and discomfort for Mr T. Accordingly the fourth and fifth complaints were also upheld. Finally, the Ombudsman upheld Mrs P’s complaint about complaint handling on the grounds that there had been an avoidable 4 month delay in providing the complaint response.
The Ombudsman recommended that the Health Board should apologise to Mrs P for the failings identified in the report and remind all nurses working at the First Hospital of relevant expectations. She also recommended that the Health Board should carry out a review of catheterisation training and of the implementation of its Deteriorating Patient Policy.