Report Date


Case Against

A GP Practice in the area of Aneurin Bevan University Health Board


Clinical treatment outside hospital

Case Reference Number



Upheld in whole or in part

Mr H complained about the care provided to his late mother, Mrs T, by 2 GPs at her GP Practice. Mr H said that at a home visit, the First GP failed to arrange “just in case” medication or to ensure plans were in place for end of life care. Mr H also complained that when his father, Mr T, telephoned the Practice because Mrs T had deteriorated, the Second GP failed to ensure she received the care and medication she needed. Mr H said that the responses to the complaint were inadequate and failed to demonstrate that meaningful learning had taken place.

The Ombudsman found that the First GP failed to prescribe “just in case” medication and that when Mrs T’s condition deteriorated, the Second GP should have returned Mr T’s telephone call, assessed the situation and arranged for medication to be urgently made available to Mrs T. The Ombudsman also found that the second GP and the Practice failed to communicate adequately with the District Nursing Service. He concluded that as a result of these failings, Mrs T did not receive medication to relieve her pain and agitation, causing her unnecessary suffering and distress and severe distress to her family, and he upheld the complaint on that basis. He did not find that the First GP failed to ensure that plans were in place for end of life care. The Ombudsman found that initial responses from the First and Second GP were inadequate and failed to demonstrate real learning from the complaint, causing additional upset to Mr H and Mr T. The Ombudsman upheld the complaint about the responses from the Practice.

The Ombudsman noted that the Practice had reflected on these events and taken appropriate action to prevent a recurrence, including an audit of its end of life documentation. He recommended that within a month of the report, the GPs apologise to Mr H and Mr T. He also recommended that within 3months of the report, the Practice should provide evidence of its audit, including any action it planned to take. The Practice agreed to implement these recommendations.