Mr Y (anonymised) was admitted to the Royal Gwent Hospital on a Thursday suffering with constipation, and the plan was to discharge him on the Friday as soon as he had opened his bowels. However due to an increase in his blood glucose levels he was kept in hospital over the weekend, despite there being a care package in place for him at home.

Mr Y’s blood glucose levels continued to fluctuate and he had difficulty swallowing with possible aspiration. Nursing staff failed to inform the medical team so Mr Y was not
medically reviewed at all on the Saturday. He was also not assessed by the Speech and Language Therapist because the service ‘does not cover weekends’.

On Sunday Mr Y developed pneumonia. The clinician on duty was informed but did not respond and nursing staff did not escalate their concerns to senior staff. It wasn’t until six hours later that a junior doctor finally reviewed Mr Y’s condition, which seriously delayed the administering of potentially lifesaving antibiotics.

His condition continued to deteriorate and Mr Y sadly died in the early hours of Monday.

Nick Bennett, Public Services Ombudsman for Wales, said:

“This case raises several concerns about the quality of patient care over a weekend. Whilst Aneurin Bevan Health Board claims that earlier medical review would not have made any difference to the tragic outcome for Mr Y and his family, I cannot be certain of that.

“In light of this I have made several recommendations to the health board including a payment of £2000 to Mrs X for the distress caused by her father’s care, a review of its escalation procedures and training for nursing staff.

“I have previously upheld complaints against the Royal Gwent Hospital which raise similar issues, and to see repetition of these issues is troubling. I published a thematic report earlier this year which highlighted my concerns about out of hours care in Wales. This case only
emphasises those concerns, and that there is a need for a review of out of hours care at the earliest opportunity.”