Aneurin Bevan University Health Board

Ms C complained about the care and treatment her late mother, Ms A, received from the Health Board when she attended Grange University Hospital (“the Hospital”) in April 2023. The investigation considered whether there was a delay in clinical assessment in the Emergency Department (ED) on arrival at the Hospital on 22 April and, if so, whether this resulted in a delay in diagnosis and treatment of sepsis (including potentially incorrect National Early Warning Score (“NEWS” – a scoring system to detect clinical deterioration) and a delay in the provision of adequate pain relief. In respect of the care and treatment provided between 23 and 24 April when on a surgical assessment unit whether the Health Board appropriately recorded and actioned consciousness levels.

The investigation found that there was a delay in a clinical assessment being carried out on Ms A on arrival at the Hospital on 22 April. There were also 2 episodes of incorrect NEWS and a delay in the provision of adequate pain relief. The Ombudsman upheld this aspect of the complaint. We found no evidence to suggest that Ms A’s consciousness levels were not documented correctly and did not uphold this aspect of the complaint.

The Ombudsman’s recommendations included the Health Board apologising to Ms C for the failings identified by the investigation and reviewing this case against relevant EG guidance identify any points of learning which can be applied in future care.

11 April 2025