Report Date


Case Against

Aneurin Bevan University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Mrs R complained about the care provided to her husband, Mr R, by Aneurin Bevan University Health Board during his admission to a psychiatric hospital ward (“the first hospital”) between 3 February and 27 June 2022. Mrs R also complained about the management of Mr R’s risk of blood clots and discharge after a brief admission to a general hospital (“the second hospital”) between 20 and 22 June 2022.

The Ombudsman found that Mr R was prescribed and given appropriate medication during his admission to the first hospital, which was in line with guidelines for the treatment of his Alzheimer’s Disease. She also found that Mr R’s mental and physical health was reviewed regularly both in-person and at weekly meetings, and his Care and Treatment Plan and medication were adjusted as necessary. Nursing staff appropriately alerted doctors to issues when necessary. These complaints were not upheld. The Ombudsman found that Mr R’s fluid intake was, generally, adequate. However, more should have been done to encourage him to drink during a heatwave and so she upheld this element of the complaint to this limited extent.

The Ombudsman found that medication to prevent blood clots was appropriately withheld when Mr R was initially transferred to the second hospital. This was because Mr R had fallen and might have had internal bleeding. The decision not to scan Mr R’s head (to confirm or rule out any internal bleeding) until the day after his transfer was not ideal, but was of a clinically acceptable standard of care. However, clot-preventing medication should have been prescribed once the risk of bleeding had been excluded and so, to this extent, this element of the complaint was upheld. The Ombudsman found that Mr R’s discharge from the second hospital (back to the first hospital) was safe and appropriate. This element of the complaint was not upheld.

The Health Board confirmed that it had already introduced a number of audits to measure and monitor quality of care through a Health Board-wide Ward Accreditation Programme. It also said that posters were being created for display on wards to remind staff, patient and visitors of the importance of drinking and the risk of dehydration, particularly during times of official heatwave.

The Health Board agreed to apologise to Mrs R for the failings identified within 1 month. It also agreed that, within 3 months, it would review its policies to ensure close monitoring of fluid intake in individual patients and at times of increased risk of dehydration. It also agreed to provide evidence of the audits relating to fluid intake and the posters that have been introduced since the time of these events. Finally, the Health Board agreed to remind relevant clinicians of the importance of reviewing patients and their need for clot-preventing medication once bleeding has been ruled out.