After being reported as missing, Ms B, (anonymised), was found outdoors and unconscious. She was admitted to the Royal Glamorgan Hospital. Ms B, who had a history of alcohol misuse and self-harm, had taken a methadone overdose and was suffering from hypothermia. She was given oxygen to assist her breathing, and underwent a chest X-ray
which was reported as clear, despite a Consultant Chest Physician later confirming the results were not normal.

The next day, despite still requiring oxygen to assist her breathing, Ms B was deemed medically fit for discharge, and following a mental health review which recorded her ‘apparent’ self-harm risk as low, she was discharged. Less than 24 hours later she was tragically found dead at home, having developed pneumonia.

Her mother, Mrs A, complained to the Ombudsman that her daughter had been discharged too quickly, and she believed that her daughter did not receive appropriate medical care.

The Ombudsman found Ms B’s discharge troubling for several reasons including a lack of clinical observations; failure to repeat vital tests; and not ensuring she could breathe unassisted, all of which may have indicated she was developing an infection.

Subsequently, the Clinical Director recognised several of the failings identified by the investigation but the Chief Executive did not acknowledge or address the clinical significance
of these in her correspondence with Mrs A.

Chris Vinestock, the Ombudsman’s Director of Investigations, said:

“It is alarming that as a result of poor discharge management, opportunities to identify Ms B’s developing pneumonia were missed. The implications of this for her family are immeasurable.

“Furthermore, the Health Board’s response to Mrs A’s concerns about her daughter’s care was inaccurate and misleading, claiming that there was no evidence of any infection despite
blood tests clearly indicating this was a possibility.

“I urge the Health Board to learn from Ms B’s death and address each of the clinical failings identified in this report, not least the development of a discharge policy. By doing so I hope that patients will no longer be discharged from hospital until all reasonable steps have been taken to ensure they are fit to do so.”