Report Date


Case Against

A GP Practice in the area of Cardiff & Vale University Health Board


Clinical treatment outside hospital; GP

Case Reference Number



Upheld in whole or in part

Miss A complained about the care and treatment provided to her late brother, Mr B, by a GP Practice in the area of Aneurin Bevan University Health Board (“the Practice”). Miss A complained specifically that between 26 January and 13 March 2023 the Practice failed to provide appropriate care and treatment to Mr B and undertake appropriate investigations into his reported breathlessness.

The investigation found that the care and treatment provided to Mr B by the Practice fell below expected standards. This is because, although an appropriate history was taken, the examination recorded on 26 January 2023 was inadequate and the follow-up or safety-netting plan was absent. The Practice failed to take appropriate action to investigate Mr B’s breathlessness as it did not make a follow-up plan to review, investigate or refer Mr B. The Ombudsman therefore upheld the complaints.

The Ombudsman recommended that the Practice should apologise to Miss A for the failings identified and provide evidence that it has reflected on the care provided and undertaken relevant learning.