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 her late husband, Mr B, not being given an opportunity to use a continuous positive airway pressure (“CPAP”) machine (to assist with breathing difficulties during sleep), while an inpatient at the Royal Gwent Hospital and the Grange University Hospital, despite its use being authorised by his Consultant. In particular, she was concerned that her husband not using a CPAP machine could have contributed to or exacerbated the heart disease from which he died. She also complained about poor communication by the Care after Death Team and the delay in that team making a referral to the Coroner’s office. Finally, she expressed dissatisfaction with Aneurin Bevan University Health Board’s complaint handling and the adequacy of the response.

The investigation found that not using a CPAP machine played no significant role in Mr B’s cardiac arrest. However, his comfort was affected and to this extent he was caused an injustice. The investigation concluded that communication could have been more effective and whilst the Health Board’s complaint response was broadly reasonable and appropriate, more could have been done to address issues around communication, and to have highlighted service change improvements in the Care after Death Team. The injustice to Mrs A included the distress caused and having to pursue her complaint further to get answers. Mrs A’s complaints were upheld to limited extents.

The Ombudsman recommended that the Health Board apologise to Mrs A and that the Care after Death Team review Mrs A’s complaint to see if there were any lessons to be learnt in relation to communication, especially when a case is being considered by a medical examiner.