Clinical treatment in hospital: Aneurin Bevan University Health Board

Ms A complained about the Gynaecology care and treatment provided to her by the Health Board. Specifically, she queried whether the diagnostic pathway for endometriosis was followed appropriately, and if the removal of her intrauterine device (“coil”) was carried out and documented appropriately, and in line with relevant guidance. She also complained about how the concerns she raised while still in hospital were addressed.

The evidence indicated that the appropriate clinical diagnostic pathway was followed so the Ombudsman did not uphold this element of the complaint. The Ombudsman was unable to reach a definitive decision regarding Ms A’s consent to the removal of the coil. However, the investigation found that documentation around this discussion could have been improved, and elements of the complaint response addressing the procedure were incorrect. Therefore, this aspect of the complaint was upheld. The investigation found that, whilst Ms A’s concerns were discussed during her stay in hospital, given the seriousness of her complaint, this could have been done earlier. It would also have been beneficial to have referred her to the Patient Advice and Liaison Service (PALS), or given her advice on how to make a formal complaint. This part of the complaint was therefore partly upheld.

The Ombudsman recommended the Health Board should apologise to Ms A for the failures identified and offer her a payment of £500 in acknowledgement of the failings in relation to recording of consent and how her complaint was handled. She also recommended that the Health Board should confirm that the Gynaecologist involved has discussed this case at his next appraisal. The Health Board also agreed to share the findings of the Ombudsman’s investigation at an appropriate Gynaecological Oncology consultant forum to ensure wider learning from the complaint, particularly the record keeping requirements around consent and obligation to provide correct information to complaint responses. She further recommended that the Health Board should ensure that information about additional support available to patients raising a potentially serious concern, such as referral to PALS, and how to raise a formal complaint, is readily available on all wards, and remind staff of their obligation to highlight these options to patients who may benefit from additional support.