Betsi Cadwaladr Patient Death “Potentially Avoidable”

Mr X (anonymised) had a history of Chronic Renal Failure along with other medical conditions. After becoming seriously ill whilst on holiday in Tenerife, Mr X was repatriated to Glan Clwyd Hospital in Rhyl, where he had received dialysis three times a week for
around two years.

Despite Mr X’s condition he waited over 12 hours to see a consultant, and sadly died a few hours later. His wife, Mrs X, complained about the decision to not immediately treat her husband in the Intensive Therapy Unit (ITU) department which she believed would have increased his chances of survival.

She also complained about the ‘misplacing’ of Mr X’s medical notes for six months following his untimely death.

The Ombudsman found a number of serious failings including:

• a lack of accessible renal consultants to provide specialist advice as they were all
away on a course

• inadequate consultant supervision of junior grade staff which led to a critical delay in admitting Mr X to the ITU

• a series of missed opportunities to provide Mr X with appropriate treatment which could have saved his life.

There were also several questions raised about the objectivity of the Health Board’s inquiry into Mr X’s death due to a series of clinical inaccuracies and the unavailability of a key document which could have altered the outcome, despite it being clearly available during
the Ombudsman’s investigation.

Nick Bennett, Public Services Ombudsman for Wales, said:

“It is a travesty that Mr X waited over 12 hours before being seen by a senior clinician and that the absence of specialist renal consultants at the hospital meant crucial dialysis treatment sadly came too late.

“Mr X’s family will always have to live with the uncertainty of knowing that had the opportunities for treatment been taken his life could potentially have been saved. This is a significant injustice.

“I have made several recommendations to the Health Board including improvements to the care pathway of renal patients and a payment of £20,000 to Mrs X for the distress caused by the manner of her husband’s death. Despite some initial reluctance I am pleased to confirm that the Health Board has now agreed to these recommendations.

“Whilst it is sadly too late for Mr X to benefit from any such improvements, I hope that as a result of this distressing case Betsi Cadwaladr will provide better renal care for patients in the future.”

ENDS