Report Date


Case Against

Aneurin Bevan University Health Board


Clinical treatment in hospital

Case Reference Number



Voluntary settlement

Mrs B complained about the care and treatment that her late mother, Mrs C, received from the Health Board when she was admitted to hospital in October 2020. The investigation considered whether appropriate risk assessments, supervision, and care plans were put in place for Mrs C, particularly in relation to falls suffered during Mrs C’s time in hospital. It also considered whether Mrs C’s clinical treatment in relation to infections she contracted while in hospital were appropriate, and if communication with Mrs C’s family was sufficient during the course of her admission (approximately 11 weeks).

The investigation found that the care provided to Mrs C between 13 October and 28 December 2020 fell below a reasonable standard. Whilst the clinical treatment Mrs C received in relation to the infections, she had contracted was reasonable (and this element of the complaint was not upheld), appropriate risk assessments, supervision and care plans were not adequately put in place and the communication with Mrs C’s family was not sufficient. This caused injustice to both Mrs C and Mrs B, and these elements of the complaint were therefore upheld.

The Ombudsman recommended that the Health Board should provide Mrs B with a written apology for the failings identified in the report and offer her £500 in recognition of the communication issues. She recommended that the final report should be brought to the attention of the nursing team, with the identified issues highlighted, and that the team should be reminded of the expected level and method of communication for updates to families, particularly when visiting is restricted. She also recommended that the Health Board should consider whether refresher training is needed in relation to risk and enhanced care assessments, and that ward management staff should be reminded of the need to review enhanced care levels daily and to ensure that the rationale for changing the level of care is clearly documented. Finally, the Ombudsman recommended that the Health Board should remind complaints handling staff of the importance of accurate complaint responses.