An elderly woman living with dementia was effectively left housebound for the last 8 years of her life due to surgical delays in the treatment and management of her severe rectal prolapse, an Ombudsman investigation has revealed.
Mr A (anonymised) complained about the care that his late mother Mrs B (anonymised), received at Betsi Cadwaladr University Health Board’s Glan Clwyd Hospital (“the Hospital”), in particular:
The opportunity to provide prudent health care with Mrs B was missed on a number of occasions as the Ombudsman investigation found that the clinical decision-making and rationale shown by the Colorectal Surgeons, consistently from 2011 onwards, in terms of Mrs B’s rectal prolapse management, was not in keeping with accepted clinical practice.
More straightforward surgical rectal prolapse repair options, including less invasive procedures, were discounted in favour of high risk, unconventional and extreme treatment options, which would have provided Mrs B with little or no clinical benefit.
The offer of only the extreme treatment option caused long term harm and significantly affected Mrs B’s quality of life. As a result of the failings, Mrs B had to cope with the considerable and ongoing indignity caused by a severe and symptomatic prolapse which included double incontinence. Mrs B’s worry about “being caught short” because of her incontinence meant she did not want to risk going to social events or the pensioner social group recommended by the dementia Memory Clinic. It also affected Mrs B’s relationship with her family and the quality of time they spent together. Although it is not open to the Ombudsman to say that there has been a breach of an individual’s human rights the Ombudsman’s investigation identified that human rights, and in particular Article 8, (relating to the right to family life and personal identity) was engaged, as the failings had such a significant impact on Mrs B’s end years and the time that the family had with her.
Betsi Cadwaladr University Health Board has agreed to a number of recommendations including a full apology to Mr A and an invitation to engage with an equivalent to the Putting Things Right Redress process. It also agreed to share the points of clinical learning from the case and to review how its Colorectal team carries out rectal prolapse procedures.
Commenting on the report, Nick Bennett, Public Services Ombudsman for Wales said:
“The lack of clinical clarity and the mixed messages given to Mrs B concerning the benefits of a colostomy meant it was only on the day of the operation, in March 2018, that she was told definitively the procedure would not benefit her prolapse. Mrs B decided not to go ahead with the operation.
“As a result, Mrs B had to endure years of indignity on a daily basis as she dealt with her condition and the longstanding physical and mental impact the failings had on her and her family.
“It is clear that there was a significant injustice in this case. As Ombudsman, given the failings that happened here, it is right that I take a stand on driving forward improvements in care and service delivery, given the effects such failings have on individuals like Mrs B, her family and their human rights.”
To read the report, click here.