Report Date


Case Against

Aneurin Bevan University Health Board



Case Reference Number



Not Upheld

Mrs A complained about the care and treatment her late mother, Mrs B, received, after transfer from the Royal Gwent Hospital (“the First Hospital”), during an admission to Ysbyty Ystrad Fawr (“the Second Hospital”) between 19 August and 8 September 2020. She complained that the Welsh Government’s COVID-19 guidance about visiting Mrs B at the Second Hospital was not followed, Mrs B’s nutrition and medication during the final weeks of her life were not managed, there was a failure to have managed Mrs B’s deterioration and to provide appropriate and dignified end of life care. Mrs A also complained that Mrs B’s medical records were not accurately maintained.

The Ombudsman found that the Health Board acted in accordance with guidance about access to the Second Hospital by visitors during the COVID-19 period. She found that Mrs B’s deterioration was managed in an appropriate and dignified manner and there were no significant shortcomings in the quality of Mrs B’s medical records.

The Ombudsman found that, aside from one prescribing error (brought about by a lack of communication between the First and Second Hospital) which had not had any adverse clinical outcome, the management of Mrs B’s nutrition and medication was appropriate. She invited the Health Board to reflect on the failure to ensure adequate transfer of clinical information between the hospitals. The Health Board acknowledged this failure and has implemented an electronic handover document for patients, backed up by a hand over between ward teams.

The Ombudsman did not uphold the complaints.