Report Date


Case Against

Aneurin Bevan University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Mrs B complained about the care and treatment that her late husband, Mr B, received from the Health Board and the Trust in 2020. In relation to the Trust, Mrs B complained that the Consultant Oncologist did not offer Mr B chemotherapy treatment, did not clearly explain the reasons for that decision, and did not tell Mr B that he had advanced cancer and stage 3 chronic kidney disease. In relation to the Trust and the Health Board, Mrs B complained that further referrals to the Trust for consideration of chemotherapy were not made or acted on at a time when Mr B was well enough to benefit from the treatment. In relation to the Health Board, Mrs B complained that there was an unreasonable delay in investigating and treating Mr B’s deep vein thrombosis, investigating Mr B’s enlarged lymph node and carrying out a biopsy following a referral by his GP. Mrs B also complained that she was not allowed to visit her husband in hospital when he was at the end of his life and that there was a delay in the Health Board responding to the complaint, as well as failing to arrange a meeting to discuss the complaint findings.

The Ombudsman concluded that it was the Consultant Oncologist’s responsibility to ensure Mr B understood his illnesses insofar as they related to the risks and benefits of chemotherapy in order to demonstrate that decisions were appropriately made. It was determined that the risks of chemotherapy were not proportionately weighed against the benefits and, although the outcome for Mr B may not have been any different, chemotherapy should have been offered. This was an injustice to him and this complaint against the Trust was upheld.

The Ombudsman did not uphold the complaint against both the Trust and the Health Board, that further referrals for chemotherapy were not made or acted upon. Some delays were identified in timescales for appointments and investigations prior to the further referral to oncology on 21 September but this would not have made a difference to the outcome or have changed the offer of treatment for Mr B.

The Ombudsman concluded that the Health Board appropriately assessed Mr B for potential DVT during his hospital admission in August 2020. Preventative blood thinning medication was prescribed and administered to Mr B due to the risk of a DVT developing as he deteriorated. A DVT was detected on 5 October, at which time the same blood thinning medication continued to be prescribed. It was also found that although there were some delays in investigating Mr B’s enlarged lymph node and completion of a biopsy, there was no indication that this resulted in the development of Mr B’s DVT or that the delay made a difference to the outcome for Mr B. The Ombudsman determined that the decisions relating to ward visiting were made in light of a COVID-19 outbreak on the ward. The national guidance in place allowed for discretion but indicated that visiting should cease where an outbreak occurred. Therefore, these complaints were not upheld.

The complaint relating to the Health Board’s handling of the complaint was upheld. The complaint response letter was delayed beyond the usual 6-month timeframe and the Health Board failed to arrange the agreed meeting with Mrs B, which prolonged Mrs B’s search for answers and was an injustice to her.

The Ombudsman recommended that the Trust apologise to Mrs B for the failings identified, review documentation relating to the chemotherapy discussion and decision in March 2020 and share the investigation findings with staff involved in his care so lessons can be learned, and they can be reminded about national guidelines.

The Ombudsman also recommended that the Health Board apologise to Mrs B for the failings identified; pay Mrs B £250 in recognition of the delays in complaint handling and failing to make arrangements for a meeting; and review its complaint handling and meeting arrangement process with those involved in the handling of the complaint, so that lessons can be learned.