Clinical treatment outside hospital; GP: A GP Practice in the area of Aneurin Bevan University Health Board Report Date 23/03/2026 Case Against A GP Practice in the area of Aneurin Bevan University Health Board Subject Clinical treatment outside hospital; GP Case Reference Number 202402831 Outcome Upheld in whole or in part Mr C complained on behalf of his late mother, Mrs A, about the care and treatment she received from her GP Practice. The investigation considered whether the management of Mrs A’s back pain from February to July 2023 was clinically appropriate. Mr C also complained about the care and treatment Mrs A received from the Health Board. However, the Health Board chose not to investigate this complaint. The Ombudsman used her discretion to investigate the matter without the Health Board having provided a response. The investigation considered whether Mrs A’s care and treatment during her first admission on 31 March 2023 was clinically appropriate and whether there should have been a follow-up. The investigation also considered whether the management of referrals from Mrs A’s GP by the Health Board was appropriate between February 2023 and her second admission on 17 July 2023.
The investigation found that the management of Mrs A’s back pain by the Practice did not reach an appropriate standard, as red flags that might have indicated Mrs A’s cancer were not identified. The Ombudsman upheld this complaint point. It also found that the care and treatment provided to Mrs A during her admission on 31 March was not clinically appropriate because she was not examined by the correct specialism and clinicians failed to consider an alternative diagnosis for her pain. The Ombudsman also upheld this complaint point. Finally, the investigation found that the Health Board’s management of referrals from Mrs A’s GP was appropriate and so this point was not upheld.
The Practice accepted the Ombudsman’s recommendations and agreed to apologise to Mr C and his family, and provide a copy of the Red Flags Guidance to all its clinicians. The Health Board accepted the Ombudsman’s recommendations and agreed to apologise to Mr C and his family, to review the case for points of learning, to remind relevant clinical staff of guidance around intimate examinations, and to make improvements to its record keeping.