Report Date

03/29/2023

Case Against

Aneurin Bevan University Health Board

Subject

Clinical treatment in hospital

Case Reference Number

202101726

Outcome

Upheld in whole or in part

Mr H complained about the care provided to his late father, Mr B, during 2 admissions to Royal Gwent Hospital and Ysbyty Ystrad Fawr.
The Ombudsman upheld the complaint about an initial decision to discharge Mr B, as he was not medically fit and appropriate plans had not been made, causing worry and distress to Mr B and Mr H. When Mr B was subsequently discharged, the causes of his symptoms had been appropriately investigated and a diagnosis made. The Ombudsman also found no evidence that Mr B had continence needs that should have been addressed, and she did not uphold the complaint. She found that it was appropriate to cancel a MRI scan arranged as an out-patient, but that on the balance of probabilities, Mr B and Mr J were not informed of the decision, resulting in inconvenience to them, and to that extent she upheld the complaint.

The Ombudsman did not uphold the complaint about the monitoring of Mr B’s food and fluid intake. She also found that Mr B’s weight loss, diarrhoea and general deterioration were properly investigated, and that his infection was promptly and appropriately treated, and she did not uphold these aspects of the complaint. She considered that it was not unreasonable for Mr B to be left unsupervised in a chair when he was having an episode of rigor, and did not uphold the complaint. However, she found that on the balance of probabilities, Mr H and his uncle were not informed of the seriousness of Mr B’s condition, and that if they had been, the shock of his death might have been lessened, although the explanations subsequently provided by the Health Board were reasonable. She upheld the complaint to a limited extent. She also found that the Health Board did not obtain information about both admissions for discussion at a meeting, resulting in a lost opportunity for Mr H to get answers to his questions, although she acknowledged that the Health Board subsequently made appropriate efforts to resolve the complaint. The Ombudsman also upheld this aspect of the complaint to a limited extent.

The Ombudsman recommended that the Health Board review its complaints procedures to ensure that, in arranging meetings with complainants, all staff involved are fully aware of the scope of the issues to be discussed, and provides evidence that it has done so.