Report Date


Case Against

Aneurin Bevan University Health Board



Case Reference Number



Upheld in whole or in part

Mr A’s concerns related to the treatment and care of his late wife, Mrs A. He complained about his wife’s care during her inpatient admission at the Royal Gwent Hospital (“the Hospital”) between 15 March and 31 March 2020, the accuracy of his wife’s clinical records and the Health Board’s over-reliance on them. Finally, he also complained about the adequacy of the Health Board’s complaint response.

The investigation found that overall the medical care Mrs A received in the emergency department was reasonable and appropriate as was her care in the intensive care unit. However, this was not the case with aspects of her later inpatient care. There were failures by the on-call Junior Doctor to recognise Mrs A’s low blood pressure, and appropriately treat her with fluids and the Surgical Doctor to recognise Mrs A’s deteriorating condition which included low blood pressure increasing NEWS and the possibility of an internal bleed. The omissions meant that Mrs A’s condition further deteriorated and the Ombudsman’s investigation concluded that this should have prompted an escalation of Mrs A’s care for senior surgical review. These shortcomings represented a significant clinical deficiency in Mrs A’s care. On the balance of probabilities, the Ombudsman was unable to rule out the possibility that earlier management and intervention could have led to a different outcome in terms of Mrs A’s subsequent cardiac arrest and severe kidney damage that followed her prolonged resuscitation. It meant that palliative chemotherapy treatment for Mrs A’s advanced cancer, which was diagnosed during her inpatient admission, was not an option because of the severity of her kidney damage. The Ombudsman concluded that the clinical failings in this case were fundamental and to that extent, unacceptable. The investigation found that the nursing care provided to Mrs A was broadly reasonable, however, some aspects – such as fluid management and monitoring – were not appropriate.

Although the Ombudsman is not able to make definitive findings on a breach of human rights she is able to comment on human rights where she considers it has been engaged. The Ombudsman was satisfied that both Mr and Mrs A’s Article 8 rights (relating to private and family life) were engaged and were impacted by the failings in care. This is because palliative chemotherapy could have afforded her additional time, no matter how limited, with her wider family at home. Moreover, Mrs A’s condition meant that hospice care was the only suitable placement for her. However, COVID-19 visiting restrictions at the hospice, where Mrs A spent her last days, meant she was unable to spend that time with her children and wider family. This was an injustice to Mr and Mrs A and their children. This aspect of her complaint was upheld.

The investigation found issues around the documentation of Mrs A’s fluid management. The failings were sufficient to uphold Mr A’s complaint about his wife’s clinical records. However, the investigation found no further reason to question either the accuracy of the clinical records or their use by the Health Board when responding to Mr A’s concerns.

In terms of complaint handling, the investigation found that the Health Board did not identify failings in Mrs A’s medical and nursing care and management (on 17 March) this reflected a lack of diligence and rigour in the investigation process. It also meant opportunities were missed to properly learn lessons and put things right quickly and effectively. This aspect of Mr A’s complaint was upheld.

The Ombudsman made a number of recommendations which included the Health Board apologising to Mr A, reminding nursing staff of the importance of completing fluid charts as well as staff reflecting on their clinical practice in order to learn lessons from this case. The Ombudsman also recommended that the Health Board share the report with all relevant medical and nursing staff involved in Mrs A’s care and ask them to reflect on its findings. Finally, the Health Board was asked to remind all junior doctors of the clinical escalation procedure.
24 January 2024