Report Date


Case Against

Trosnant Lodge


Clinical treatment outside hospital; GP

Case Reference Number



Not Upheld

Ms B complained that for an 8-month period, a GP Practice in the area of Aneurin Bevan University Health Board (“the Practice”) failed to offer her an in-person consultation and appropriate care and treatment for nasal and breathing problems. She since had received a cancer diagnosis. Sadly, Ms B died before the conclusion of the investigation.

The Ombudsman found that although Ms B should have been offered an in-person GP consultation during the 8-month period, it was not likely that it would have necessitated a referral or alternative care and treatment at that time. Therefore, the level of injustice was limited. There was no evidence that Ms B reported symptoms to the Practice that should have resulted in an urgent chest X-ray referral. There was no evidence to suggest that the Practice should have suspected that Ms B had lung cancer, or to have initiated investigations that may have detected it – even with the benefit of hindsight. Although a review identified shortcomings in the Practice’s standard of record keeping, which the Practice was asked to reflect upon, this did not clinically impact the outcome for Ms B. The Ombudsman did not uphold the complaint.