Report Date


Case Against

Aneurin Bevan University Health Board


Clinical treatment in hospital

Case Reference Number



Voluntary settlement

Ms A complained that appropriate gynaecological investigations including around her urinary stress incontinence had not been carried out in a timely and reasonable manner. She was also dissatisfied with the way that referrals had been handled and the Health Board’s handling of her complaint.

The Ombudsman found a substantial delay in one referral being taken forward. The referral was made in November 2018 but the response was not received until June 2020, and only chased by the Gynaecologist in May 2020, after Ms A raised it. There was also no explanation given for the delay either in the medical records or in the Health Board’s complaint response.

The Ombudsman also found that the process behind the Gynaecologist’s letter to Ms A’s GP, about an incidental abdominal scan finding of fatty liver, did not accord with the British Medical Association’s (“BMA”) guidance. This was because no discussion had taken place with the GP to get their prior agreement to take forward this aspect of Ms A’s care and treatment. The Ombudsman concluded that the Health Board’s complaint response was not sufficiently robust on this point, nor did the Health Board’s policy appear in keeping with the BMA’s guidance.

As part of the settlement the Health Board agreed to apologise for the shortcomings identified around the referrals and complaint handling and to provide an explanation for the delayed referral. Finally, the Health Board agreed to review its processes to see if lessons could be learnt regarding the delayed referral and to review, and if necessary update its policy, to reflect BMA guidance and to update its clinicians accordingly.