Report Date


Case Against

Aneurin Bevan University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Ms D complained that, prior to undergoing the surgical insertion of a Suprapubic Catheter (an “SPC”) at the Royal Gwent Hospital, she was not fully informed of the precise details of the procedure. She complained that it was not explained to her that, while under general anaesthetic, the insertion of the SPC would be guided by a cystoscope which would be introduced into her bladder via the urethra. Ms D said that she would not have opted for the procedure had she known this, given her history of urethral pain and trauma. Ms D also complained that:

a) A urology registrar who provided her care was insensitive and unprofessional in tone and manner.

b) At no time during her admission was she reviewed by a consultant urologist.

c) She was discharged without appropriate antibiotics for a urinary tract infection (“UTI”). As a result, she was re-admitted some weeks later with symptoms of infection.

d) An information leaflet given to her about the SPC procedure did not explain that the bladder would be accessed with a cystoscope via the urethra.

The Ombudsman upheld complaints a) and b) and partially upheld complaint c) (finding that Ms D was discharged without appropriate antibiotics but that this was not the cause of her re-admission some weeks later). He did not uphold complaint d). With regard to Ms D’s substantive complaint about consent, the Ombudsman did not uphold this on the basis that there was compelling evidence that the consent process was thoroughly conducted. Whilst the Ombudsman accepted Ms D’s assertion that she did not fully understand that the procedure entailed cystoscopic guidance via the urethra, he was satisfied that a sufficient amount of information about the procedure (including the use of a cystoscope) was provided by clinicians in 2 separate discussions, in a patient information leaflet and in the completion of the consent form in which risks and after-effects were recorded. The Ombudsman found no evidence to suggest that Ms D was not given sufficient opportunity to digest this information and to raise questions and/or seek clarification on any matter that she was unclear or concerned about.

The Ombudsman recommended that Aneurin Bevan University Health Board (“the Health Board”) provide Ms D with a fulsome written apology for the failings that were identified, together with a redress payment of £250 in recognition of the time and trouble to which she was put in escalating her complaint.

He also recommended that the report be discussed with the Urology Registrar at his next appraisal and that the Health Board provides details of the measures taken to ensure that patients requiring antibiotics on discharge (on the basis of blood culture results) are issued with them before leaving the hospital.

The Health Board accepted these findings and agreed to implement the recommendations.