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Mr F (anonymised) was admitted to the Prince Philip Hospital in Llanelli in May 2014 for a scheduled hip replacement operation. This was carried out without complication and Mr F was recovering well.
A junior doctor reviewed Mr F the following day but he was not seen by a senior physician for the next three days, and two subsequent consultant visits weren’t recorded. Mr F was later deemed fit for discharge but when his family arrived to collect him, his condition had deteriorated.
Whilst a junior doctor diagnosed an intestinal blockage with possible sepsis, Mr F’s additional condition of cardiac failure was never considered.
Mr F appeared to stabilise and his family returned home to allow him to rest. Shortly afterwards Mr F’s blood pressure dropped alarmingly, and he suffered a fatal cardiac arrest.
Ms D contacted the Ombudsman to complain about her father’s care after the Health Board failed to adequately respond to her concerns. The Ombudsman found that:
• Despite Mr F’s medical history putting him at risk of heart disease, no pre-operative ECG[i] or chest x-ray were carried out
• Due to lack of support, junior doctors failed to diagnose Mr F’s cardiac condition which consequently led to an inappropriate care management plan
• His family weren’t informed of the seriousness of his condition, denying them the opportunity to be with him when he died
• The Health Board failed to acknowledge the incomplete diagnosis and its implications.
Commenting on the report, Nick Bennett, Public Services Ombudsman for Wales, said:
“It is extremely worrying that junior level staff were left unsupervised to make significant clinical decisions. The alarming lack of medical notes and failure to recognise Mr F’s heart condition meant that opportunities to escalate him to the Medical Emergency Team were missed.
“Not only did Mr F’s family wait over 13 months for a response to their concerns which in itself is unacceptable, that response failed to acknowledge the incorrect provisional diagnosis and its dire implications.
“This case demonstrates a catalogue of serious failings which, together, create significant doubt around whether Mr F’s death was, as the Health Board suggested, inevitable.”
[i] Electrocardiogram – a test for problems with the heart’s electrical activity