Report Date


Case Against

Aneurin Bevan University Health Board


Clinical treatment outside hospital

Case Reference Number



Upheld in whole or in part

Miss X complained about investigations and treatment carried out by her GP Practice and the Health Board into a cervical mass. She also complained about how both organisations dealt with her complaints.

The Ombudsman found that the investigations and treatment of Miss X’s cervical mass were broadly reasonable, albeit there was a delay in the Practice making a referral on one occasion. In addition, the Health Board did not copy Miss X into a letter setting out the results of a biopsy and took her off the list for an appointment after the letter inviting her to the clinic was not sent to her. Although none of these failings ultimately affected Miss X’s treatment, they did cause her needless anxiety and time and trouble when attempting to resolve matters. To that extent the complaints were upheld.

In relation to the handling of Miss X’s complaints, the Ombudsman found that when Miss X made a complaint about both organisations via the Health Board’s contact centre, the Health Board did not pass on the complaint about the Practice. As the Practice was unaware of it, it was unable to respond to Miss X’s complaint. For that reason the Ombudsman did not uphold the complaint about the Practice. He did uphold the complaint against the Health Board. In addition to the failure to pass on the relevant parts of the complaint to the Practice, the Health Board also wrongly treated the complaint about its own actions, as being resolved informally, when it should have sent a formal response.

The Ombudsman recommended that the Health Board should apologise to Miss X and pay her £250 in recognition of the time and trouble she had been put to due to the shortcomings in how it handled her complaint.

It also recommended that the Health Board should issue guidance to its Gynaecology Directorate about when complaints may be dealt informally and when a formal response is required.