The Ombudsman launched an investigation after a complaint was made about the care received by Mrs A (anonymised) in May 2017 from Cardiff and Vale University Health Board.
The Ombudsman found that the Health Board failed to recognise that Mrs A was at high risk of Acute Kidney Injury because of her age and existing health concerns, including acute kidney failure, from the time she was admitted. In an attempt to control Mrs A’s back pain, she was prescribed pain relief at inappropriate levels (in the context of her pre-existing kidney failure) and, even when she began to decline, this was not reviewed.
The failure to monitor Mrs A’s medication and kidney function resulted in an acute kidney injury, which was probably preventable but was overlooked. Failures to recognise the impact on Mrs A’s kidneys, monitor her hydration or change her medication meant that it went untreated and she became more unwell and sadly died.
The Ombudsman also found that a prescription of an antidote to counter the accumulation of opioid pain killers, which could not be filtered by Mrs A’s damaged kidneys, was prescribed too late. Consequently, there was significant uncertainty about whether Mrs A’s death could have been avoided, had appropriate action been taken sooner.
He also criticised the Health Board for significant delays in the reporting, processing, investigating and managing of two safeguarding concerns raised by Mrs A’s family. The first concern was raised following the appearance of bruising and the second concern was about Mrs A’s symptoms of slurring, losses in consciousness and apparent “fitting”, which appeared to the family to indicate that she had suffered a head injury but were more likely to have been attributable to the medication she was prescribed and the impact it was having on her kidneys.
Commenting on the report, Nick Bennett, Public Services Ombudsman for Wales, said:
“I am extremely concerned that Mrs A was prescribed pain relief at inappropriate levels with no safety checks and that even when she began to decline, neither her kidney function nor the medication she was prescribed were reviewed.
“It is also worrying that medication to counter the effects of opioid toxicity was not administered soon enough. There is uncertainty over whether Mrs A’s death might have been avoided had appropriate action been taken sooner. This is a terrible injustice that Mrs A’s family are left to live with.
“Additionally, the Health Board acknowledged that following an allegation made by a family member regarding bruising to Mrs A, the relationship between her and staff was negatively influenced by the fact that the concern had been raised. This is concerning and could represent a wider culture which may prevent patients from raising issues. Reporting a complaint and action taken should be seen as a positive act in that it assists organisational learning.”
The Health Board has agreed to a number of recommendations including providing a full and meaningful apology to the family of Mrs A and to offer financial redress of £5,500.