Report Date


Case Against

Aneurin Bevan University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Mr B’s complaint related to the standard of care provided in June 2021 to his late mother, Mrs A, when she was transferred from ICU (the Intensive Care Unit) to ward-based care. Specifically, he raised concerns about the arrangements for handover to the ward, and whether Mrs A received appropriate pain assessment and medication on the ward following the transfer.
The Ombudsman found that a referral to the Palliative Care team should have been made prior to Mrs A’s discharge from ICU. This would have helped ensure continuity of care for the planned transfer to ward care. This part of the complaint was upheld.
In relation to the medication given, the Ombudsman found that ward staff continued the same medication regime, using the same medication and pain assessment charts, started in ICU. The evidence indicated regular assessment for pain and administration of medication when needed, and this aspect of the complaint was not upheld.
The Health Board confirmed that, as a result of the complaint, it had reviewed its checklist on discharge from ICU to enable smooth transfers to ward-based care. This included ensuring that a referral to the Palliative Care team had been made for relevant patients. It had also provided additional palliative care training for staff and was considering implementing a behavioural pain assessment tool.