Report Date


Case Against

Aneurin Bevan University Health Board


Clinical treatment in hospital

Case Reference Number



Not Upheld

Mrs N complained that Aneurin Bevan University Health Board (“the Health Board”) failed to provide her with appropriate care while she received blood transfusions and discharged her inappropriately after the transfusions were complete. Mrs N also complained that the GP Practice failed to appropriately assess and treat Mrs N’s symptoms in her left foot and leg when she was seen 4 days after her discharge.

The Ombudsman found that Mrs N was appropriately monitored during the blood transfusions and that it was appropriate not to prescribe treatment to prevent blood clots. She was appropriately monitored during the transfusions and her discharge and the plan for follow-up care were clinically appropriate. There was no clinical reason for Mrs N to stay in hospital once her blood transfusions were complete. These elements of the complaint were not upheld, although the Ombudsman invited the Health Board to consider how it could ensure that patients are informed of appropriate self-care following blood transfusions, and the warning signs of a negative reaction.

The Ombudsman found that the documented assessment of Mrs N’s foot and leg when she was seen at the GP Practice was inadequate. Relevant clinical findings were omitted and indications of the severity of her reduced blood flow were misinterpreted. Mrs N should have been referred urgently to the Vascular Team but, as a result of these failures, her referral and assessment by that team was delayed by at least 24 hours. This delay did not materially impact the clinical treatment Mrs N received, which ultimately required her leg to be amputated. However, if the GP had considered all the relevant factors and appropriately referred Mrs N for an immediate review by the Vascular Team, this could have reassured her that her concerns were taken seriously and that everything possible was done, even if this would not have saved her leg. This element of the complaint was therefore upheld.

The GP Practice agreed to apologise to Mrs N, remind all doctors within the GP Practice of the importance of maintaining comprehensive documentation and also demonstrate that all doctors have refreshed and updated their knowledge of reduced blood flow to a limb, including relevant symptoms and the actions that should be taken. The GP Practice agreed to complete these actions within 1 month. It also agreed that, by 31 December 2024, the GP who undertook the consultation would consider Mrs N’s case and the findings of this report as part of his annual appraisal process.