Mr R (anonymised), 92, had undergone a total hip replacement following a fall at home and was subsequently discharged to a Community Hospital in the Aneurin Bevan University Health Board area for rehabilitation.
A complaint was made by Mr R’s son that staff at the Community Hospital failed to identify, manage and treat his father’s post-operative infection or arrange for his transfer back to the District General Hospital, for treatment, appropriately.
The Ombudsman found that:
Commenting on the report, Public Services Ombudsman for Wales, Nick Bennett, said:
“With regards to Mr R’s wound treatment, it’s deeply concerning that despite the patient’s son and nursing staff raising issues, both the Doctor and a Tissue Viability Nurse seemed to be unaware of appropriate best practice.
“Had Mr R’s infection been successfully addressed, Mr R may not have developed the subsequent pneumonia which lead to his death, and this is a heart-breaking injustice for the family of the patient.”
The Health Board has agreed to a number of recommendations including an apology and £2,000 to Mr W in recognition of the service failures identified and the repercussions of those failings for Mr R.