Report Date


Case Against

Aneurin Bevan University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Mr A complained about the care and treatment provided to his late wife, Mrs A. In particular, Mr A complained that the Health Board failed to:
• Take appropriate measures to prevent and manage skin damage during Mrs A’s hospital admission between 13 May and 21 June 2021;
• Put in place an appropriate plan of care to prevent and manage further skin damage prior to Mrs A’s discharge from hospital on 21 June 2021;
• Provide appropriate community-based care for Mrs A’s skin damage between June and September 2021; and
• Arrange a timely referral to the tissue viability service in relation to Mrs A’s skin damage.

The investigation found that following Mrs A’s discharge on 21 June, the district nursing referral was delayed and incomplete and that she suffered an injustice as a result. Accordingly, the Ombudsman upheld that part of the complaint. The investigation found that, otherwise, the care and treatment provided to Mrs A during her admissions to hospital between May and October 2021 and the district nursing care provided was reasonable and appropriate. For that reason, the remaining complaints were not upheld.
The Health Board agreed to the Ombudsman’s recommendations to apologise to Mr A for the failings and injustice identified and to remind relevant staff of the importance of making timely and complete referrals for district nursing care when arranging the discharge of patients who are at very high risk of pressure damage.