Report Date


Case Against

Aneurin Bevan University Health Board



Case Reference Number



Not Upheld

Mr A complained that there was an unacceptable 11 hour delay by the Welsh Ambulance Services NHS Trust (“WAST”) in an ambulance attending his late mother, Mrs M, on 3 and 4 November 2019. He also complained about WAST’s handling of his complaint. The Ombudsman’s predecessor decided to use his “own initiative” investigation power under Section 4 of the Public Services Ombudsman (Wales) Act 2019 to extend the existing investigation into WAST to include the actions of Aneurin Bevan University Health Board (“the Health Board”) in accordance with the Ombudsman’s criteria for commencing such an investigation. The Ombudsman extended the investigation to consider whether there was any maladministration or service failure on the part of the Health Board which contributed to the time Mrs M had to wait for an ambulance and to be seen in the Emergency Department (“ED”), once the ambulance arrived at the Royal Gwent Hospital (“the Hospital”).
The Ombudsman’s investigation concluded that the calls to WAST were correctly categorised and appropriate searches were made to try to source an emergency ambulance to attend the calls. It was evident that delays transferring patients into the care of the Health Board seriously affected WAST’s ability to respond on this occasion. The Ombudsman was also satisfied that WAST’s complaint response was reasonable, and did not uphold Mr A’s complaint.

The Ombudsman was satisfied that care provided to Mrs M on 3/4 November was broadly reasonable in the circumstances and the delay did not adversely affect Mrs M. However, she noted that the delays must have been distressing for both Mr A and his mother.

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The Ombudsman was satisfied that the ED was under extreme pressure on 3/4 November due to the number and complexity of patients, which was compounded by staffing issues; the ED staff escalated their concerns to senior staff who were aware of the impact on the efficiency of the ED and took action, although the Ombudsman was unable to further comment on this.

The Ombudsman noted that this case and a Healthcare Inspectorate Wales (“HIW”) review had highlighted that the issue of prolonged handover delays outside EDs was a national problem across Wales. The Ombudsman invited the Health Board to consider working with other health boards and WAST on how best it can put into practice the recommendations contained within the HIW review. The Ombudsman invited the Health Board to bring this report is brought to the attention of its Chief Executive and the Chair of its Patient Safety Group and if it does not already do so that the issue of prolonged handovers becomes a standing item on the agenda at Board level. The Ombudsman was mindful that the handover delays may potentially have a detrimental impact upon the ability of the healthcare system to provide responsive, safe, effective, and dignified care to patients and suggested that the Health Board considers any learning from this case in order to tackle the root causes of delays in patients being transferred.

24 June 2022