Source · PSOW (Public Services Ombudsman for Wales)

Aneurin Bevan University Health Board

PSOW (Public Services Ombudsman for Wales) Not Upheld Reference PSOW-202407336 Sector Health Category Clinical treatment in hospital Decided 24 March 2026

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Miss A complained about the care and treatment that she received during her inpatient admission at Royal Gwent Hospital (“the Hospital”). The investigation considered whether it was clinically appropriate for the prescribed cyclizine (an antihistamine and antiemetic drug for management of nausea) to be changed from intravenous to oral administration, for the prescribed dosage to be decreased and whether these aspects of the treatment plan were communicated appropriately to Miss A.

It also considered if Miss A was afforded appropriate support from mental health services during the extended time that she was an inpatient, in particular, after she took an overdose on 23 January 2024.

Finally, the investigation considered whether the Health Board appropriately reported on, recorded and investigated the overdose at the time of the incident.

The investigation found that the prescribed dosage of cyclizine was consistent and the dosage and mode of administration were both in keeping with standard practice. Miss A was kept informed of the management plan but there was a missed opportunity to ascertain why she was intent on being prescribed the medication via IV; however, this did not amount to a service failure.

There was no evidence within the clinical records that Miss A had requested psychiatric input, rather, it was recorded that support was appropriately offered at various points during admission, but declined by Miss A who had capacity to make that decision.

The clinical actions taken in response to Miss A’s overdose were appropriate; however, the incident was not reported in line with expected process. The Health Board has, during the course of this investigation, retrospectively recorded the incident. I am satisfied that Miss A did not suffer an injustice as a result of this omission as she received appropriate care regardless of the failure to document the incident. Nevertheless, the Health Board has been invited to remind all staff within the Urology and Medical teams of the importance of reporting and recording incidents to ensure that future risk is reduced, and that lessons can be learned. The complaints were not upheld.

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