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 treatment he received from the Health Board between 2019-2021. The investigation considered whether treatment of Mr A’s spinal injury while in the Emergency Department was appropriate, specifically his first assessment, the initial decision to discharge him; whether appropriate checks were conducted after he fell from bed in hospital; his aftercare for his back fracture, and if the information about his recovery period and advice provided was appropriate and the pain medication prescribed was sufficient. It also considered if the investigations undertaken in relation to his urology issues were sufficient and if the delay in his ADHD referral and appointments were excessive.

The investigation found that the majority of Mr A’s spinal treatment was appropriate. However, further checks should have been done before the initial decision was made to discharge him home from the ED, painkillers should have been prescribed earlier, further X-rays should have been done, information about his recovery should have been detailed in his records and discharge letters, and pain management medication prescribed in hospital should have been continued upon discharge. Whilst there was no evidence to suggest any of these had a significant effect on Mr A’s overall recovery, together they were indicative of service failure and an injustice to Mr A, so this complaint was upheld. The investigations undertaken in relation to Mr A’s urology issues were found to be appropriate, and, although there was some delay in undertaking an ADHD referral, there was a clear rationale for this and the delay was not excessive. These complaints were not upheld.

The Ombudsman recommended that the Health Board should provide Mr A with a written apology in relation to the shortcomings identified in the report, and should also remind relevant staff of the necessity of recording important information in relevant documentation. She also recommended that it should bring the investigation to the attention of complaints handling staff as a reminder of the importance of issuing accurate responses in line with PTR and should also reflect on the concerns identified in relation to communication and record-keeping, consider any measures that could be put in place to limit such issues.