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:

  • Appropriate dressings were not used at any time throughout Mr R’s care and at one-point telephone advice was given to use a stoma bag to collect the discharge, instead of making proper arrangements for wound care and using an appropriate dressing.  Furthermore, Mr R’s wound clips remained in situ throughout his admission, which was likely to have exacerbated his infection.
  • There was no comprehensive review of Mr R or his wound by a doctor after the initial admission assessment, despite clear evidence that infection was present.
  • Senior medical advice should have been sought promptly from the District General Hospital and the failure to do so delayed appropriate treatment for Mr R by at least a week, which made it more difficult to treat the infection, and for Mr R to fight it.
  • The Health Board failed to ensure that it had fully informed the Welsh Ambulance Services Trust of Mr R’s condition, so that appropriate transport could be arranged to transfer him back to the District General Hospital.

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.