Ms C (anonymised), who works for Betsi Cadwaladr Health Board handling complaints, complained to the Ombudsman after staff missed several opportunities to identify and prevent her father’s (Mr D) deterioration which led to him suffering a fatal cardiac arrest.

Mr D was admitted to hospital in December 2014 with a chest infection. He suffered with COPD[i] and was diagnosed with pneumonia and respiratory failure. His NEWS[ii] score was calculated at 8, which should have prompted his transferral to a high dependency unit. However there was delay in finding Mr D a bed and he was not seen by a consultant until the following morning.

A day later Ms C was informed that Mr D was improving and discharge plans were discussed. However his condition worsened over the next 24 hours and his medical records indicated he had acute kidney injury secondary to sepsis, but this was never treated. On Christmas Day, four days after admission, Mr D suffered a cardiac arrest and died.

Ms C complained to the Health Board in February 2015. Almost a year later Ms C had still not received an update and she sought the help of a Community Health Council advocate. During this time Ms C claimed a Betsi Cadwaladr employee involved in her father’s care made inappropriate comments about the complaint to a family member; the Health Board failed to follow this up properly.

Nineteen months after receiving the original complaint the Health Board sent their response. Whilst they admitted failing to carry out key observations and incorrectly calculating Mr D’s NEWS score, they claimed that these did not affect the sad outcome.

Following investigation the Ombudsman found a number of serious failings including:

  • Missed opportunities to take action which may have prevented Mr D’s deterioration and subsequent death
  • Inaccurate recording of the cause of Mr D’s death
  • Failure to carry out a Serious Incident Report despite this being referred to in the complaint response.

Commenting on the report, Nick Bennett, Public Services Ombudsman for Wales, said:

“I find it extremely concerning that the Health Board refuses to admit that had they approached Mr D’s care differently, his death could have been prevented. Not only was the care substandard in this case, I find the Health Board comments disingenuous and indicate an unwillingness to accept the seriousness of the situation. Furthermore the cause of Mr D’s death was wrongly recorded causing even more distress to the family which is unacceptable.

“The fact that a member of its own staff, accustomed to the concerns process, found the Health Board’s approach to her complaint so frustrating that she was forced to seek assistance from an advocate, does not instil confidence for members of the public using the system.

“I urge the Health Board to learn from this case and address the serious clinical failings. By doing so I hope that patients requiring critical care will not be overlooked in the future.”

[i] Chronic Obstructive Airways Disease

[ii] National Early Warning Score – used to establish the degree of illness of a patient using various observations