Report Date


Case Against

Aneurin Bevan University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Ms A complained to the Ombudsman about the care provided to her late mother, Mrs B, at the Royal Gwent Hospital (“the Hospital”) in particular:

• that physicians failed to adequately investigate Mrs B’s symptoms of severe abdominal pain, vomiting and weight loss during 2 admissions (from 19 – 20 November and from 26 November to 19 December 2018)

• that, on both occasions, Mrs B was discharged with inadequate support (and pain control) and being unable to cope at home, was re-admitted within days

• that physicians failed to detect/report an occlusion (blockage) in the superior mesenteric artery (“SMA”) which was visible on CT scans conducted on 19 November and 7 December 2018. Ms A said that this delayed medical treatment and/or surgical intervention and, consequently, questioned whether the outcome of Mrs B’s care and treatment might have been different had the blockage been detected.

• Finally, Ms A complained that the Health Board’s handling of her complaint/concern under the Putting Things Right Scheme (“PTR”) was deficient and excessively protracted, and communications with her were poor, infrequent and unhelpful.

The Ombudsman found that, although the investigations undertaken during the first and second admission were appropriate, clinicians should have undertaken further investigations during Mrs B’s second admission in the absence of a clear diagnosis for the cause of her unresolved pain. The Ombudsman upheld this complaint to that limited extent.

The Ombudsman found that, although the decision to discharge Mrs B from the first admission was appropriate, there was insufficient evidence that clinicians had adequately considered her pain relief requirements. The
decision to discharge Mrs B from the second admission was inappropriate and again, clinicians had failed to properly consider her pain relief requirements. The Ombudsman upheld this complaint to that extent.

The Ombudsman found that the occlusion identifiable on the first 2CT scans was not reported on, delaying Mrs B’s diagnosis. However, the delay had limited clinical impact as an earlier diagnosis was unlikely to have altered either the treatment plan or outcome. The Ombudsman did not uphold this complaint.

The Ombudsman found that the Health Board’s complaint handling was avoidably protracted and lacked appropriate updates to Ms A. The Ombudsman upheld this complaint.

The Ombudsman recommended the Health Board apologise to Ms A and pay her £250 in recognition of the time and trouble in pursuing her complaint. She also made recommendations for reminders to staff concerning pain relief, assessment and investigations where there is no
diagnosis, and information being supplied to radiologists. The Health Board agreed to implement the recommendations.