Miss B complained about the inpatient care and treatment provided by the Health Board’s Ysbyty Glan Clwyd (the First Hospital) and Llandudno Community Hospital (the Second Hospital) to her late father, Mr B. The investigation considered aspects of Mr B’s diabetic management, surgical clinical decision-making including about not amputating Mr B’s toe and the monitoring of Mr B’s skin condition.
The investigation found that surgical decision-making was clinically reasonable and appropriate. In terms of Mr B’s diabetic management, the investigation identified that clinical and administrative failings, relating to poor documentation, contributed to Mr B experiencing more hypoglycaemic episodes than might have been the case with better management. For example, there were unnecessary delays in a referral being made to the diabetes specialist nurse team and a dietician, despite evidence of Mr B’s poor food intake. The physical and cognitive effects on Mr B, and the impact this had on the family was an injustice. It was to this extent only that this part of Miss B and the family’s complaint was upheld.
The investigation also found that, although there was evidence of skin and wound monitoring and nursing intervention, documentary shortcomings meant that Mr B’s skin and wound management was not always clear. Given his arterial disease, whatever preventative care and / or wound care was provided to Mr B, might not have changed the outcome. Despite this, given the at times poor documentation, this left a degree of uncertainty around Mr B’s clinical management, which was an injustice for Mr B and the family. It was to this limited extent only that this part of Miss B and the family’s complaint was upheld. Recommendations included an apology to the family, training, changes in process and an audit with an action plan to follow up any further failings identified.