Report Date


Case Against

Aneurin Bevan University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Mrs A complained about the management and care her mother Mrs B received at Ysbyty Ystrad Fawr and later at Grange University Hospital managed by Aneurin Bevan University Health Board (“the Health Board”). Mrs A complained that when her mother became unwell after her discharge home on 10 July 2021, she should have been re-admitted to the First Hospital on 12 July and that her mother’s discharge on 27 July following an inpatient admission was unsafe. Mrs A also complained about the poor communication with the family about her mother’s end of life care. Finally, Mrs A said that there was a delay in complaint handling, due to her original complaint not being registered and felt the complaint response was not robust.

The Ombudsman’s investigation found that when Mrs A’s mother became unwell after her discharge home on 10 July, she should have been re-admitted to Ysbyty Ystrad Fawr hospital on 12 July for further assessment. Whilst the failure to admit Mrs B was a service failure, the Ombudsman was satisfied that this did not lead to any significant harm. The Ombudsman was also satisfied that clinically Mrs B’s discharge was safe and that communication with Mrs A and her family about Mrs B’s end of life care was appropriate and reasonable. These aspects of Mrs A’s complaint were not upheld.

The Ombudsman concluded that the Health Board’s investigation and subsequent complaint response was not sufficiently robust since it did not identify/address the shortcomings around the mismanagement of Mrs A’s complaint. To this limited extent only this aspect of Mrs A complaint was upheld and a financial redress of £250 recommended.