Report Date


Case Against

Aneurin Bevan University Health Board



Case Reference Number



Upheld in whole or in part

Ms B complained about her late mother, Mrs C’s, treatment in 2 hospitals within the Health Board’s area. She queried whether the Health Board:

• Should have done more to assist in obtaining new dentures for Mrs C after they went missing during her admission?

• If the insertion of a feeding tube was necessary, as a direct consequence of Mrs C missing her bottom dentures?

• If the feeding tube should have been re-inserted after it became dislodged during transfer to the Second hospital?

• If a failure to administer blood thinning medication as prescribed, resulted in clinical harm to Mrs C?

• If Mrs C understood the implications of agreeing to no further needles and tubes on the day before her death, given her clinical situation?

• If she had been given an appropriate update on Mrs C’s clinical condition on the morning of her death, and should have been contacted to sit with Mrs C before she died?

The Ombudsman found that whilst staff were aware of the missing dentures, and made several entries in Mrs C’s medical notes about the need to replace them, no action was taken to progress this. The Ombudsman also found that Ms B did not appear to have received a full update on the date of her mother’s death informing her of the severity of her condition. Although COVID-19 restrictions limited visitor access, the Ombudsman found that it should have been apparent that Mrs C was nearing the end of her life, and therefore Ms B should have been given the option to visit her. These were injustices to Mrs C and her family, and these elements of the complaint were therefore upheld.

The investigation found that Mrs C was offered a variety of food and drink, that could be consumed without dentures, but Mrs C either refused or only took small amount of these, so although the missing dentures were one reason for the feeding tube, it could not be proved that it was the only or main reason the tube was needed. The investigation found that multiple attempts were made to re-insert the tube, without success, and that whilst the Health Board had already apologised for the error in not administering Mrs C’s blood thinning medication for 3 days, the evidence did not suggest this had a significant effect on Mrs C’s subsequent deterioration. The evidence available reflected that Mrs C had sufficient understanding at the time she made her decision about not wanting further tubes and needles. These elements of the complaint were therefore not upheld.

The Health Board agreed to apologise in writing to Ms B for the failings identified in the report, and to share the report with relevant staff to facilitate learning. It also agreed that it would create formal guidance for the treatment of patients who have dental issues while in hospital.