Report Date


Case Against

Aneurin Bevan University Health Board



Case Reference Number



Upheld in whole or in part

Mr A complained about the care and management that his late wife Mrs A received at the Royal Gwent Hospital and the Grange University Hospital during her last admission in December 2020. He questioned why his wife was moved to a COVID-19 ward when she was “low positive” and given insulin when her blood sugar was low and causing hypoglycaemia (low sugar level due to diabetes). Mr A complained that the blood transfusion caused an adverse reaction, and he believed, that the blood did not match his wife’s ethnicity. Mr A also complained about ineffective communication. He felt that the nurses might have been “racist”. Finally, Mr A remained unhappy with the robustness of the Health Board’s complaint response.

The Ombudsman’s investigation concluded that it was reasonable and appropriate to have moved Mrs A to a COVID-19 ward when she developed a temperature and after appropriate steps were taken to test for, and diagnose COVID-19. The Ombudsman was also satisfied that Mrs A was treated appropriately with insulin as and when required and that there was no evidence that she was administered the insulin “forcefully” or that she suffered an adverse reaction to the insulin. The Ombudsman found no evidence that there were complications or side effects from Mrs A’s blood transfusion and noted that the donor bloods were tested against Mrs A’s blood sample for matching, and that ethnicity matching was not a requirement for blood transfusion. Accordingly, those aspects of Mr A’s complaint were not upheld.

The Ombudsman’s investigation found failings in communication with Mr A and Mrs A. The Ombudsman highlighted that whilst she was unable to make definitive findings about whether discrimination, harassment or victimisation had occurred under the Equality Act, she could comment if she considered it appropriate to do so. She was satisfied that the Health Board’s policy on language and interpreting services was followed.

The Ombudsman was critical that communication with Mr and Mrs A about Mrs A’s critical health condition was not as effective as it could have been especially during the COVID-19 pandemic when visiting was restricted, and relatives were dependent on being updated by staff about the clinical status of their loved ones. As a result, Mr A was left unclear as to his wife’s condition and prognosis. The Ombudsman was largely satisfied with the Health Board’s complaint response, but was critical that the Health Board’s investigation did not identify the failings around communication which meant that opportunities to learn lessons were missed. This caused Mr A an injustice. These aspects of Mr A’s complaints were upheld and the Health Board was asked to apologise to Mr A.