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 that the sedative medication given to her late husband, Mr A, on 8 September 2021 during his inpatient admission to Grange University Hospital was not appropriate. Sadly, Mr A, who had chronic health conditions, suffered a cardiac arrest during this admission and died the next day. Mrs A also said that there was inadequate communication with the family about her husband’s deteriorating condition. She also complained about the Health Board’s complaint handling and the inadequacies in its complaint response of 4 April 2023.

In terms of the sedation medication, the Ombudsman said that clinicians were entitled to prescribe the sedative haloperidol, to treat Mr A’s acute confusion even though prescribing guidance meant that there were contraindications due to Mr A’s presenting heart condition. However, the Ombudsman was critical that the reason for not following prescribing guidance was not documented and that there was no management plan documented around the prescribing and administering of haloperidol. Whilst the Ombudsman could not say definitively what role, if any, haloperidol played in Mr A’s subsequent cardiac arrest and death, the Ombudsman concluded that the injustice for Mrs A was that she would have to live with the uncertainty of not knowing whether her husband’s outcome might have been different if haloperidol had not been administered. This part of Mrs A’s complaint was upheld.

The Ombudsman did not find inadequacies when it came to communication with the family and did not uphold this part of Mrs A’s complaint.

The Ombudsman was critical about the Health Board’s complaint handling and complaint response around Mr A’s sedation medication. The Ombudsman’s found that the family had not been told about a medication error that had led to Mr A being given too much of another sedative nor had the fact that Mr A had been prescribed and administered haloperidol been mentioned. The Ombudsman concluded that Mrs A had been caused an injustice, as the Health Board’s lack of openness and transparency had contributed to Mrs A’s mistrust of the Health Board and meant she had to complain further to get answers. This part of Mrs A’s complaint was also upheld.

The Health Board agreed to the Ombudsman’s recommendations that it should apologise to Mrs A for the clinical failings identified as well as the shortcomings around complaint handling. The Health Board was also asked to remind clinicians of the importance of documenting a clear clinical rationale and management plan when prescribing guidance is not followed.