Report Date


Case Against

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



Case Reference Number



Upheld in whole or in part

Mrs A complained that the GP Practice (“the Practice”) failed to provide satisfactory care to her mother, Mrs B, and that this contributed to her rapid terminal decline in April 2020. Further, Mrs A said the Practice’s handling of her complaint was not adequate or robust. Mrs A also complained about the community nursing care provided the Health Board and about a telephone consultation with an Out of Hours GP (“the OOHGP”) on 15 April. Finally, Mrs A complained about the Oncologist at Velindre NHS Trust (“Trust”) and their communication with the family as well as the Trust’s complaints handling.

The Ombudsman’s investigation found that, broadly, the consultations by the GPs were appropriate and that Mrs B’s rapid decline and death could not have been anticipated. However, given Mrs B’s sudden deterioration, a face-to-face consultation would have been helpful, especially as it later delayed the family getting a death certificate. Although this shortcoming did not contribute to Mrs B’s sudden deterioration, or alter the sad outcome, it added unnecessarily to the family’s distress at a difficult time. The complaint against the GP Practice was upheld to this limited extent.
The Ombudsman also found shortcomings in the record keeping by the District Nurses’ that failed to provide adequate handover information for continuity of care. Records were also added retrospectively after Mrs A had complained. Although the investigation concluded that a home visit by the OOHGP was not necessary following the telephone consultation, given that there was every indication that Mrs B was likely to be close to death, this should have been discussed with Mrs A so that she was better prepared. The Ombudsman found that these communication failings caused an injustice to Mrs A and the family as it added to their distress at a very difficult time and this aspect of the complaint against the Health Board was upheld.

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The Ombudsman identified administrative shortcomings around documentation and communication by the Oncologist who failed to notify Mrs B’s GP about a significant change in her treatment and to copy correspondence with the GP to Mrs B. There was also a failure to communicate significant information about Mrs B’s deterioration to clinical teams following contact by Mrs A with its Helpline. The Ombudsman was also critical of the Trust’s complaint handling. The investigation was not robust and failed to identify a number of shortcoming identified by the Ombudsman. There were also factual inaccuracies in its’ complaint response. These shortcomings caused the family added distress and injustice and these aspects of the complaint against the Trust were upheld.

The Ombudsman recommended that each of the public bodies should apologise to Mrs A for the failings identified. Additionally, recommendations were made around improved record keeping by the Health Board. The Trust was also asked to review its processes around the Helpline service to improve communication of significant clinical information.