Report Date


Case Against

Aneurin Bevan University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Mr A complained about the care and treatment provided to him by Aneurin Bevan University Health Board. The investigation considered whether the Health Board investigated his symptoms properly during consultations in June and October 2021 and whether diagnosis earlier than August 2022 would have resulted in earlier treatment of his oropharyngeal cancer (a type of head and neck cancer).

The investigation found that that the consultations of 14 June and 5 October were of a clinically acceptable standard. There was no evidence to suggest that there were missed opportunities to refer Mr A for further investigation during these consultations. The Ombudsman did not uphold the complaint.

In respect of whether an earlier diagnosis would have resulted in earlier treatment of Mr A’s oropharyngeal cancer, the investigation found that a later consultation with Mr A on 31 May 2022 was clinically appropriate, but the requested procedures should have been carried out sooner. This would probably have resulted in Mr A’s treatment commencing earlier. Whilst it was likely that Mr A’s treatment plan would have been the same had he been diagnosed more promptly, Mr A suffered avoidable mental distress because of the delay, which was an injustice to him. The Ombudsman upheld Mr A’s complaint.

The Health Board agreed to provide Mr A with a meaningful apology for the failings identified and to make a redress payment to him of £500. Additionally, it agreed to provide a reminder to clinicians to consider expediting biopsy procedures where there is evidence of a new mass and risk of malignancy, and to remind clinicians about the policy for patients presenting with a tonsil mass to arrange all imaging scans at the first appointment.