Ms A complained about care provided by the Health Board to her late partner Mr B. The Ombudsman’s investigation considered whether the Health Board provided prompt and appropriate care to Mr B at Morriston Hospital after staff were alerted to his medical emergency.
The investigation found that it was unlikely that there was sufficient evidence to determine whether maladministration of service failure occurred. However, the Ombudsman was concerned that the available evidence indicated that there may have been some confusion about where to find a defibrillator in order to provide emergency care to Mr B in the hospital car park. It also appeared that not all staff involved in the response were fully aware of the details of the Health Board’s policy for responding to medical emergencies on the grounds of the hospital, but not in hospital buildings. The Ombudsman considered that there was scope for lessons to be learned to improve the way staff on the site respond to similar emergencies in the future.
The Health Board agreed to carry out a review within 3 months of current policies and procedures for responding to cardiac arrest or similar clinical emergencies on the grounds of Morriston Hospital but not inside the hospital buildings. It will carry out this review with reference to the care provided to Mr B. The review should have input from the Emergency Department, staff working at the ambulance triage station and any other relevant staff. It should include consideration of whether sufficient guidance is available to relevant staff in terms of roles and responsibilities and in relation to where a defibrillator will be sourced from.
It should also consider whether any other specific learning points can be identified that might lead to a better co-ordinated response should a similar scenario occur again.
The Ombudsman considered that, taking into account the limitations of the available evidence, it was appropriate to settle the complaint on the basis of the above action.