Source · PSOW (Public Services Ombudsman for Wales)

Aneurin Bevan University Health Board

PSOW (Public Services Ombudsman for Wales) Not Upheld Reference PSOW-202200414 Sector Health Category Clinical treatment in hospital Decided 17 May 2023

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Full decision

Mrs A complained about the care and treatment her late husband, Mr A, received from Aneurin Bevan University Health Board (“the Health Board”). Specifically, she complained about whether Mr A was appropriately reviewed by the Cardiology Department, including in relation to ensuring that his intensive medication regime was not having a detrimental effect on his internal organs (specifically his pancreas). Mrs A also complained about the care Mr A received at the Emergency Department (“ED”) and the decision not to admit him to the Intensive Care Unit (“ICU”) prior to his death from acute necrotising pancreatitis.

The Ombudsman found that, although there were administrative oversights which resulted in two Cardiology review appointments not being undertaken, these appointments would not have identified the acute pancreatitis which ultimately caused Mr A’s death. The Ombudsman also found no evidence to suggest that Mr A’s medication regime contributed to the development of his pancreatitis and that additional monitoring of his pancreas was not necessary.

The Ombudsman found that there was a delay in a doctor assessing Mr A in the ED, but that this was not clinically significant in terms of the eventual outcome. The investigation found that the clinical care Mr A received and the decisions taken not to escalate care to the ICU were appropriate.

The complaints were not upheld.

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