Mr C complained about the care and treatment he received from the Health Board. The investigation considered whether the routine fitting of a catheter for Mr C, performed by the District Nurse Service on 25 September 2023, was carried out appropriately, and whether this could have resulted in Mr C’s need to be hospitalised and treated for infection.
The Ombudsman found that the catheterisation of Mr C was not carried out appropriately, and was not in line with clinical standards. In addition, the Health Board’s explanation about what happened did not align with how events were recorded in Mr C’s clinical records. The investigation found that, on the balance of probability, these failings introduced an increased infection risk which was likely to have resulted in Mr C’s hospitalisation and infection. This was an injustice to Mr C. The Ombudsman upheld this complaint.
The Health Board agreed to provide a written apology to Mr C for the failings identified in the report and to share the report with the District Nurse involved in Mr C’s catheterisation, to consider and reflect upon the findings. The Health Board also agreed to introduce an audit/review process, if not already in place, to monitor staff compliance/completion against expected training requirements, and to share the investigation report with the Health Board’s Quality and Safety Meeting for discussion and reflection on the identified failings.
