Source · PSOW (Public Services Ombudsman for Wales)

Aneurin Bevan University Health Board

PSOW (Public Services Ombudsman for Wales) Not Upheld Reference PSOW-202502263 Sector Health Category Clinical treatment in hospital Decided 20 April 2026

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Mr F complained about the care his father, Mr G, received from the Health Board following a diagnosis of an aggressive brain tumour, including the management of Mr G’s falls risk and his potential need for hospice care between January and May 2023. Mr F also complained about the management of Mr G’s medication and blood sugar levels, and the communication with the family during Mr G’s final admission to hospital between 22 and 30 May.

The investigation found that, unfortunately, balance problems and falls were an inevitable outcome of Mr G’s diagnosis and deterioration, but he was resistant to intervention and dismissive of concerns and suggestions for support. Similarly, Mr G wanted to stay in his own home. Mr G had capacity to make these decisions and there were no failings on the part of the Health Board to consider what level – and location – of care and support was appropriate. These complaints were not upheld.

In relation to Mr G’s inpatient admission, the investigation found that there were occasional missed doses of Mr G’s steroid and blood pressure medication, and that his blood sugar levels were not monitored as often as they should have been. However, Mr G was not always compliant to take his medication or have blood tests. Furthermore, there was no evidence that these things had any clinical impact for Mr G or the progression of his disease. The investigation also found that appropriate updates were provided to the family, and that information was shared when it was requested. There was no evidence to suggest that the hospital staff could have known (and therefore prepared the family) for Mr G’s sudden demise. These concerns were also not upheld.

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