Report Date


Case Against

Aneurin Bevan University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Mrs K complained about the care provided to her father, Mr C, by Aneurin Bevan University Health Board. She said that a doctor should have attended to him during a 10-hour period overnight, shortly before his death.

The Ombudsman found that nursing staff repeatedly requested a medical review of Mr C, which should have prompted the On-Call Team to attend. The care provided and the telephone advice given were in line with appropriate clinical standards, but the lack of direct medical review left Mrs K feeling like she and her father had been abandoned at the end of Mr C’s life, which had a lasting effect on her in her grief and was a significant injustice. Additionally, the failure of the On-Call Team to attend to review Mr C was not escalated by staff in line with the Health Board’s Deteriorating Patient Policy. This failure to escalate meant that consideration and oversight of why the On-call team had been unable to attend did not take place. The complaint was upheld.

The Health Board agreed to apologise to Mrs K, to remind relevant staff of the importance of completing necessary documentation and of the escalation procedure from the Deteriorating Patient Policy. It also agreed to demonstrate that there is a robust process in place to identify the causes of non-attendance and take action to mitigate the risks of those causes reoccurring.