Mr O complained on behalf of his wife, Mrs O, about care provided to her by Betsi Cadwaladr University Health Board (“the Health Board”). The investigation considered whether the Health Board failed to provide appropriate dressings for a wound to Mrs O’s left buttock between February and August 2024 and whether it failed to provide adequate assistance for Mrs O to safely access the taxi rank after she left Ysbyty Gwynedd Emergency Department (“the ED”) on 27 June 2024.
The investigation found that on 16 March Mrs O had requested continuation of the previous wound care regime established before she moved to the Health Board’s area, but the Health Board’s clinicians recommended a change of approach without providing an adequate rationale. It was not until 17 July that district nurses recognised that the previous regime was more appropriate for Mrs O’s needs. The investigation found that the available evidence did not support that sufficient dressings were provided by the Health Board to meet Mrs O’s wound care needs prior to 17 July.
While the types of dressings recommended by the Health Board’s clinicians were not inappropriate generally, there was a failure to recognise that they were not suitable for Mrs O, taking into account that her method of mobilising and patterns of activity caused her to need frequent daily dressing changes. The investigation found that, had the Health Board appropriately considered and addressed Mrs O’s needs sooner, the need for Mr and Mrs O to purchase dressings privately could have been avoided or at least reduced. This was an injustice to them.
Accordingly, this part of the complaint was upheld. The Ombudsman made a number of recommendations including, an apology and a financial redress payment of £1000 to Mr and Mrs O for injustices caused by these failings. She also recommended service improvement actions, including a reminder of expected care standards for relevant clinicians and a review of procedures for managing patients who move to the Health Board from another area.
The investigation found, on the balance of probability, that Mr and Mrs O asked a member of the ED Reception team for a wheelchair to allow Mrs O to transfer to a taxi on 27 June. It also found that there were services available to support Mrs O to travel home from the ED, but that Mr and Mrs O were not made aware about these services. It was not possible, on the available evidence, to establish whether this was due to miscommunication amounting to maladministration. This complaint was not upheld, but the Ombudsman invited the Health Board to reflect carefully on Mrs O’s experience and consider what steps it could take to minimise the chance that other patients would leave the ED without adequate support.