Betsi Cadwaladr University Health Board was also criticised for the “deplorable length of time” it took to deal with the subsequent complaint concerning the failings.

Mr M (anonymised) was admitted to Glan Clwyd Hospital in Rhyl for planned surgery to remove bowel cancer. Despite follow-up blood tests showing abnormal CRP levels indicating that Mr M had a leak in his bowel, the results were not reviewed by senior clinicians and his
condition deteriorated rapidly. He underwent further emergency surgery to repair the leak but sadly died the following day from severe sepsis, just a week after his admission.

His daughter, Ms A, complained to the Ombudsman that despite raising concerns about Mr M’s post-operative care several times with nursing staff, these were ignored and not documented, which she believed ultimately led to her father’s death. She also complained
about the Health Board’s poor handling of her complaint, having waited eight months for a response.

The Ombudsman found a number of serious clinical deficiencies including:

• a failure to recognise and monitor Mr M’s abnormal CRP levels as well as other
warning signs that he was not recovering as he should be.

• a lack of senior review of vital blood test results which led to missed opportunities for early intervention.

• a failure to carry out basic sepsis management.

Questions were also raised about the integrity of the Health Board’s investigation into Mr M’s care, which failed to recognised the failings highlighted by the Ombudsman’s
investigation and concluded that Mr M’s care had been appropriate.

Nick Bennett, Public Services Ombudsman for Wales, said:

“Whilst I accept that any surgery carries with it a degree of risk, I cannot ignore the likelihood that had clinicians intervened sooner in Mr M’s post-operative care the outcome could have been very different.

“Mr M’s family will never be sure whether his death could have been avoided and will have to live with knowing that there were missed opportunities for potentially life-saving
treatment, which is a significant injustice.

“I am also extremely disappointed that the Health Board’s review of Mr M’s care fell significantly short of what I regard as acceptable, as well as taking a deplorable length of time to respond to Ms A’s complaint.

“I have made several recommendations to the Health Board including making a payment of £8,000 to Ms A for the distress caused by its failings. Whilst the Health Board claims to have learnt from this case, and that it will prioritise the use of the sepsis care pathway from now
on, it is sadly too late for Mr M.”