Report Date


Case Against

Aneurin Bevan University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Mr C has complained about the care and treatment his wife, Mrs A, received from Aneurin Bevan University Health Board (“the Health Board”) when she presented to the Emergency Department (“the ED”) at Grange University Hospital (“the Hospital”) in January 2021. He complained about the failure to diagnose Mrs A’s first stroke when she presented to the ED on 25 January 2021; as well as failings in nursing and medical care during the weekend of 19 February around a stroke diagnosis. Finally, he was dissatisfied with the Health Board’s complaint handling and the robustness of its complaint response.
The investigation found that based on Mrs A’s symptoms it might have been reasonable to consider if a small stroke had occurred during her January admission. Given this, she should not have been discharged until discussions had taken place with other relevant clinicians such as the stroke specialists, neurologists and radiologists and further examination, specifically a doppler ultrasound, carried out. The Ombudsman was also concerned that a key clinical discussion with Mrs A about being discharged, and an MRI and other investigations being carried out as an outpatient was not documented in Mrs A’s clinical records. In the absence of such documentation, it was not possible to say that such a discussion took place. The investigation concluded that this administrative failing was not only maladministrative but was also not in-keeping with the General Medical Council’s guidance on record-keeping. That said, the Ombudsman was satisfied that any delay in treatment planning would not have altered Mrs A’s outcome. The service failings identified meant that Mrs A and her family would be left with the uncertainty of not knowing whether she suffered a small stroke during this admission. Consequently, they were less prepared than they might have been when she suffered a major stroke following her discharge home and this was an injustice to Mrs A and her family. It was to this limited extent only that this aspect of Mr C’s complaint was upheld.
Mr C’s complaints about failings both in nursing and medical care and communication with the family during the weekend of 19 February were not upheld.
The investigation found complaint handling delays were not unreasonable. However, a lack of sufficient depth and rigour in the Health Board’s investigation was identified. This meant that Mr C had to spend unnecessary additional time and trouble in pursuing his concerns. That was an injustice to him and this aspect of the complaint was upheld.
The Health Board was asked to apologise to Mr C and provide a financial redress in the sum of £250 in recognition of the distress caused to him by the failings in complaint handling. The Health Board was also asked to provide training to relevant clinicians on the National Institute of Care and Excellence Guidelines, and to remind them of the need to document all relevant information accurately within patients’ medical records.