An 87-year-old woman died after a Health Board failed to take prompt and appropriate action to assess and treat her symptoms of a stroke, the Public Services Ombudsman for Wales has found.
The Ombudsman launched an investigation after receiving a complaint about the care given to Mrs T (anonymised) between June and August 2017 by Swansea Bay University Health Board, previously known as Abertawe Bro Morgannwg University Health Board.
The Ombudsman found that the Health Board failed to undertake an appropriate assessment of Mrs T’s risk of a stroke, even when her family raised concerns that she appeared to have a left-sided weakness, facial droop and slurred speech.
He also found that when doctors were asked to review Mrs T’s condition in light of her family’s concerns, two separate clinicians failed to document their attendance, assessment or findings. A third clinician failed to note whether any symptoms of a potential stroke were considered at all.
In addition, the investigation found that there was a failure to appreciate that a severe deterioration of Mrs T’s condition, following gastroenterological complications, meant that she was too unwell to proceed with a planned X-Ray on 23 August 2017. It was following this X-Ray, as she was being returned to the ward, that Mrs T died.
The Ombudsman also criticised shortcomings in record-keeping relating to the care provided to Mrs T.
“I am extremely concerned at the failure to adequately assess and treat the stroke symptoms that Mrs T presented with, even after her family intervened. By the time Mrs T’s stroke was diagnosed on the afternoon of 27 June, it was too late to administer the appropriate medication.
“I also found the lack of adequate records and notes relating to the clinical care of Mrs T worrying. For example, my investigation found that Mrs T was probably malnourished, as she experienced significant weight loss during her admission. Unfortunately, this was not addressed owing to errors and omissions in the records, which resulted in an unnecessary three-week delay in making a dietician referral.
“Furthermore, I found that Mrs T experienced severe anxiety and was probably suffering from delirium during her time in hospital. Whilst the decision not to prescribe sedatives was acceptable clinical practice, owing to the patient’s high risk of breathing difficulties, specialist input should have been sought to establish whether any other intervention could help alleviate her anxiety. Such advice might have provided some reassurance to the patient’s family, who felt that their concerns were dismissed and ignored.”
The Health Board has agreed to several recommendations, including:
To see the report, click here.