WHEN Celia Jones' partner Brian Boulton died at the Royal Gwent Hospital on Wednesday September 27 2017, she was unable to be at his side.

Nursing staff did not tell her of his rapidly deteriorating condition in time, and she was not visiting that day because she had been ordered not to.

Three days earlier, Ms Jones' visits had been restricted to one hour, twice a week, by senior medical and nursing staff concerned about her alleged behaviour on the ward, and the alleged administration by her to Mr Boulton of a larger than prescribed dose of a diuretic drug.

But after a lengthy investigation, the Public Services Ombudsman for Wales has upheld her complaints about what she calls her unfair and "appalling" treatment.

Also upheld is her complaint about a failure to spot Mr Boulton's oesophageal cancer on a CT scan a month before he died.

"I was falsely accused of something I regard as a criminal act. I feel vindicated, but it's been more than two years, and it's been very difficult," said Ms Jones, who lives in Newport.

"It's been awful. I've not felt able to grieve for Brian properly and I was accused of some awful things. I was treated appallingly, and because they didn't contact me in time, I couldn't be with Brian when he died.

"I want this story told, because this sort of thing could happen to anybody."

The heart of Ms Jones' complaint centred on Mr Boulton's stay at the Royal Gwent from September 18 2017 until he died.

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The health board claimed she told a senior ward manager during a telephone call, and later a junior doctor, that she gave Mr Boulton (above) a double dose of diuretic drug furosemide - which had been prescribed for him.

Ms Jones said she was in the ward when the alleged phone call took place on September 18, that it did not happen, and that a record of it was falsified.

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Aneurin Bevan University Health Board maintained it was a contemporaneous record - but the Ombudsman's report describes the call note as 'typed and untimed'. There is no reference to it in the records and the investigation manager said: "I consider it to be poor record keeping practice to add notes on loose paper to the records".

"A properly recorded, contemporaneous record of a conversation would support the health board's comments... I do not consider this evidence alone to be a reliable, contemporaneous record as claimed".

The records state Ms Jones phoned the ward that evening, but there is no reference in the records to furosemide.

The report states too, that the issue was discussed with Mr Boulton, by a junior doctor, with Mr Boulton saying that he took his own medication, and the doctor saying Ms Jones had disclosed that she gave it to him.

It describes the doctor's recording of the matter as "inconsistent" and that overall, accounts conflict and evidence is not consistent.

But the health board did not raise its concerns with Ms Jones until it was decided, on September 25, to restrict her visiting hours.

She told the Argus that within minutes of arriving to visit Mr Boulton that day, "I was called into a room and accused of giving him unprescribed furosemide".

"It was awful. I was told, 'you need to be contained'," she said.

"They said I could come in for one hour on Tuesday September 26, not on the Wednesday, and one hour on Thursday September 28.

"I came in on the Tuesday, stayed for the hour, and never saw him alive again.

"He died on the Wednesday. The day I wasn't supposed to visit."

Late that afternoon his condition deteriorated and the hospital did not get in touch with her until an hour after this became obvious. By the time she arrived, he was dead.

Despite the restrictions, the Ombudsman's report states that the health board assured Ms Jones that if Mr Boulton's condition deteriorated, she would be contacted.

"In the event, it did not do this," it states, adding that it is a "significant injustice" that she was unable to be with him when he died.

The Ombudsman's report states that record reflect that Ms Jones' behaviour on the ward "had become very challenging for staff" between September 21-24. But visiting restrictions, it says, were imposed "without warning", against its own policy, and there are concerns about how she was informed.

She had, it says, "arrived at the hospital alone, anticipating a visit with her very ill partner.

"She was called into a room with four senior staff, yet she was not given a reasonable opportunity to have someone with her to provide support.

"I am of the view that the health board did not take into consideration whether Ms (Jones) was vulnerable, or seek to mitigate the impact of the news it was about to deliver.

"Furthermore, the health board provided Ms (Jones) with no warning prior to implementing the restriction, and no process by which she might have appealed it. This was unfair."

It also raises concerns that Mr Boulton's voice was not heard regarding this decision, noting anxieties about his decision-making capacity during his admission. But it states that while the health board did not consider Ms Jones a suitable advocate for him, opportunities that would have led to the appointment of someone who was were not taken before the restrictions were imposed.

Ms Jones's complaint about improper implementation of a Deprivation of Liberty Safeguards process regarding Mr Boulton - which may have enabled his voice to be heard in the above matter - and of a 'do not attempt CPR' decision, was also upheld.

Another complaint upheld by the Ombudsman concerned care relating to a CT scan Mr Boulton had a month before he died.

It revealed oesophageal cancer that had spread to lymph nodes, and should have triggered an urgent cancer referral, but this was not spotted, and no referral was made.

It is unlikely Mr Boulton could have been saved, given the cancer's advanced stage, but the report concluded that opportunities were missed, to provide support in putting his affairs in order and to discuss his prognosis with Ms Jones and other loved ones.

Ms Jones' further complaint about Mr Boulton's care during his September hospital admission was partly upheld, as was another relating to the health board's handling of her original complaint.

In the report, Ms Jones referred to as Ms Y and Mr Boulton as Mr Z.

A health board spokesman said: “Our thoughts remain with the family and friends of Mr Z. The health board has offered its apologies to Ms Y and we are very sorry for those elements of Mr Z’s care which were found to be below the expected standard, despite the best efforts of our staff.

"We have fully co-operated with the Public Services Ombudsman for Wales’ Office inquiry and provided information to aid their independent investigation.

"We have accepted the recommendations outlined in the report, a number of which we have already addressed in response to the original complaint from Ms Y in 2017.

"As a health board, we are fully committed to learning and making improvements to the care that we provide, including improving the experience for patients and their families.”