Report Date


Case Against

Aneurin Bevan University Health Board


Clinical treatment outside hospital

Case Reference Number



Early resolution

Ms A complained about a significant delay on the part of the Health Board in vaccinating her mother, Mrs B, against Covid-19, and the detrimental impact this had on Mrs B and the family. Ms A also complained about the Health Board’s inadequate investigation of, and response to, her complaint.

The assessment of the complaint identified the following concerns. District Nursing Service input appeared not to have been sought internally when the Health Board investigated this complaint which led to an incomplete complaint response being provided to Ms A. The Health Board acknowledged that, due to an administrative error, Mrs B’s Covid-19 vaccination was delayed significantly meaning that she was unable to see her terminally ill son before he sadly died. There was a failure to properly escalate Ms A’s concerns when she raised those with the District Nursing Service (and the GP Practice).

To resolve the complaint, the Health Board agreed to provide Ms A with a meaningful apology for the shortcomings identified; to provide Ms A with a further written response seeking to explain what happened in this case after obtaining the input of the District Nursing Service and the relevant GP Practice, if necessary; to arrange an internal audit to establish how the administrative error occurred and to learn lessons and to consider how the escalation process can be improved. The Health Board agreed to undertake these actions within 3 months.