Report Date


Case Against

Aneurin Bevan University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Mrs A complained about the care and treatment that her late mother, Mrs X, received during her admission from 13 July 2020 until 9 August 2020 (the day of her death). Specifically, that clinicians failed to facilitate her having direct telephone contact with her mother, that this lack of contact exacerbated Mrs X’s confused condition and the decision to address this with antipsychotic medication was not appropriate, that a Deprivation of Liberty Safeguard (“DoLS”) authorisation completed in respect of Mrs X failed to adhere to legal and regulatory requirements, and that the Health Board had not adequately explained the rapidity of Mrs X’s physical and psychological decline, which occurred within a matter of days of her admission.

The investigation found that more should have been done to facilitate telephone contact between Mrs A and Mrs X. This avoidable distress was an injustice to Mrs A and Mrs X. This part of the complaint was upheld. The investigation found that the use of an antipsychotic was appropriate and in accordance with recognised guidance. However, communication with Mrs A about Mrs X’s treatment was poor and the lack of contact between Mrs A and Mrs X may have increased the distress and confusion Mrs X suffered. This was an injustice to Mrs X, and the uncertainty this leaves Mrs A with about the quality of her mother’s care is an injustice to Mrs A. This complaint was upheld to that extent. The investigation found that the urgent DoLS referral was appropriate and made in the best interests of Mrs X. This aspect of the complaint was not upheld. The investigation found that communication with Mrs A was extremely poor and fell well below the standard she should have received. This complaint was upheld.

The Ombudsman recommended that the Health Board provide Mrs A with a written apology for the failings identified in this report and remind staff who care for patients with dementia of the requirements and benefits of good communication with families/carers and the importance of documenting this appropriately. It should share the report with clinical staff involved in Mrs X’s care to facilitate reflective learning.