A 69-year-old cancer patient died after “numerous significant failings” were made in her care and discharge from hospital by a north Wales Health Board and local authority, the Public Services Ombudsman for Wales has found.

The Ombudsman launched an investigation after receiving a complaint about the care given to Mrs M (anonymised) in August 2020 by Betsi Cadwaladr University Health Board and Denbighshire County Council.

The Ombudsman found that clinicians at Glan Clwyd Hospital and Llandudno General Hospital failed to “adequately investigate and appropriately treat” Mrs M’s abdominal pain and weight loss symptoms, which she developed following bowel surgery. He also found that clinicians failed to assess Mrs M’s frail condition accurately and discharged her without appropriate home care support in place, which led to her being re-admitted to hospital.

In addition, the Ombudsman found that a secondary cause of Mrs M’s death – an ischaemic bowel – was not identified from scans or investigations conducted during her admissions.

The Ombudsman also criticised the Health Board and Local Authority for failing to coordinate their response to a complaint from Mr D, Mrs M’s son, which resulted in the Council’s response being received six months after that of the Health Board.

Commenting on the report, Public Services Ombudsman for Wales, Nick Bennett, said:

“This tragic case involved an alarming, systemic misdiagnosis. Numerous significant failings and deficiencies took place before, during and after Mrs M’s discharge from hospital.

“These failings impacted upon Mrs M’s human rights in terms of her dignity but also her quality of life. There was also an impact on the patient’s family’s rights in terms of witnessing her debilitating decline”.

The Ombudsman recommended that both bodies provide Mr D with fulsome written apologies and a redress payment of £250. He also recommended that the Health Board makes a redress payment of £5,000 in recognition of the distress that the findings of his report will cause to Mrs M’s family.

Additionally, he recommended that the Health Board demonstrates evidence that physicians and relevant nursing teams referred to in the report have undergone training in:

  • the diagnosis and treatment of small bowel obstructions (SBOs).
  • the theory and practice of the use of contrast media in CT scans and the clinical contexts in which the threshold for CT investigations should be lowered.
  • the medical management of nutritional needs.
  • the Health Board’s Discharge Policy, specifically the importance of documenting actions, plans and developments surrounding the discharge process.

Both the Health Board and the Council accepted the findings and conclusions of the report and agreed to implement these recommendations.

To read the full report, click here.