Report Date


Case Against

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


Clinical treatment outside hospital; GP

Case Reference Number



Upheld in whole or in part

Mrs X complained that there was no proper examination or assessment of her late husband, Mr X’s condition during a GP consultation in August 2021. As a result, no appropriate treatment or referral for further investigation was made.
Whilst the ultimate diagnosis would not have been altered, the Ombudsman found no evidence to indicate that an appropriate assessment of Mr X’s presenting symptoms, or proper examination, took place during the consultation. The response to the complaint by the GP Practice was also inadequate resulting in Mrs X having to pursue her complaint to the Ombudsman.
The Ombudsman upheld the complaint and the following recommendations were agreed:
• The GP Practice should review and discuss the complaint at a Significant Event Analysis (SEA) meeting.
• The GP Practice should provide a further written apology to Mrs X reflecting the Ombudsman’s findings, and explain the outcome of the SEA meeting.
• The GP should discuss the complaint, and his learning from it, at his next annual appraisal.
18 April 2023