Summary

Ms A complained about the care she received from Betsi Cadwaladr University Health Board (“the Health Board”) and Liverpool University Hospitals NHS Foundation Trust (“the First English Trust”). Her concerns included her management and care following surgery for her inflammatory bowel disease in 2019, whether she was properly consented for surgery to address her fluid collections and pelvic infection in March 2022, as well as the post-operative care and treatment and the handling of her complaint.

The investigation found that following Ms A’s surgery in 2019 the Health Board’s management of her post-operative fluid collections was appropriate, but there were failings in the colorectal care provided by the First English Trust. The Ombudsman noted that Ms A should have been reviewed and monitored more closely, although it could not be definitively said that this would have prevented sepsis.

The Ombudsman also found issues with gynaecological referrals made to another NHS Trust, the appropriateness of an investigative procedure and the lack of preventative antibiotics given. These failings led to persistent infection and ill health for nearly 3 years before definitive surgical treatment in March 2022.

The investigation identified shortcomings in the consent process, and the Ombudsman concluded that Ms A did not give informed consent for the surgery in March 2022. This raised human rights considerations, particularly regarding personal autonomy and the right to respect for private and family life. The injustice for Ms A included not having an opportunity to reconcile herself to the likely outcome of the surgery or to explore options to have biological children in the future. The impact on Ms A, both physically and psychologically, was significant.

The investigation also highlighted a failure to provide information and advice about hormone replacement therapy, leaving Ms A to experience menopausal symptoms without clear management.

In respect of the handling of Ms A’s complaint, the Ombudsman found delays in complaint handling but did not consider the delay unduly excessive. The Health Board relied on the First English Trust to handle parts of the complaint which it was able to do, but there were shortcomings in the First English Trust’s response.

The Ombudsman was concerned that in its contract monitoring of commissioned care, the Health Board prioritised financial reporting over patient safety and service quality. She considered that effective contract monitoring might have prevented some failings in Ms A’s care.

The Ombudsman made a number of recommendations, which the Health Board accepted.

Within 1 month:

a) Apologise to Ms A for the failings identified in the report.

b) Share the report with the Chair of the Health Board and the other Board members and its Patient Safety and Clinical Governance Group.

Within 2 months:

c) As part of its commissioning arrangements, request the First English Trust undertake and evidence the following:

i. a review of Ms A’s case to see what additional learningcould be identified to improve the patient experience;

ii. a reminder to its clinicians of the relevant guidance aroundinformed consent and their professional obligations when it comes to record keeping to ensure that discussions with patients are documented;

iii. as a point of learning, it shares with clinicians an anonymisedcase study of the clinical failings identified in the case at an appropriate clinical forum;

iv. the Colorectal Surgeon is asked, as part of learning and reflection, to share a copy of this report and discuss the steps that she has put in place to improve her clinical practice at her next professional revalidation;

v. a copy of the report is shared at its relevant patient safety governance committee.

In addition, the Health Board should:

d) Seek written assurances from the First English Trust’s Chief Executive that it has taken steps to address the clinical failings identified in the report.

e) Share the compliance evidence relating to recommendations c) and d) with the Ombudsman’s office.

Within 6 months:

f) Prioritise, complete and implement a Commissioning Assurance Framework.