New Public Interest report issued by Public Services Ombudsman for Wales finds failings in nursing care for Ms A, an adult with learning disabilities. In addition to failing to monitor and manage Ms A’s pain and epilepsy, Betsi Cadwaladr University Health Board also failed to communicate with her and support her personal care needs, nutrition and hydration.

The Complaint

The Ombudsman launched an investigation after Ms D complained about the care and treatment her sister, Ms A, received from Wrexham Maelor Hospital in July 2022.

Ms A had several medical conditions, including epilepsy, cerebral palsy and learning disabilities. She lived in a nursing home, had limited communication, and required 24 hour care and support.

What the Ombudsman found

The Ombudsman found failures by the Health Board:

1. To fully support and communicate with Ms A, in respect of her personal care needs, her nutrition and hydration.

On the occasions that the Learning Disability team and Ms A’s family were not present to assist, the nursing care on the ward fell short of acceptable standards, especially at weekends and overnight.

There was no person-centred nursing care plan setting out the care objectives and adjustments that were needed to provide Ms A with effective care. This meant that staff did not fully understand her needs.

2. To monitor and manage Ms A’s pain, including medication administration.

There were many occasions when Ms A’s pain was identified by her family and the Learning Disability team, but it was unclear whether nursing staff were consistently able to identify her pain. The assessment tool they used was not adapted for Ms A’s particular needs.

This meant that Ms A suffered unnecessarily as identifying she was in pain depended on whether someone who knew her was present at the time.

3. To monitor and manage Ms A’s epilepsy, including medication administration.

The Ombudsman found a poor standard of record keeping in relation to Ms A’s seizures. It was unclear whether nursing staff recognised Ms A’s seizures and, had her family not been present, it is likely that many of her seizures would have gone unnoticed.

Administration of medication was found to be inadequate. Poor compliance with anti-seizure medication may have contributed to the increase in Ms A’s seizure activity.

4. Its handling of the complaint

The Ombudsman found that the Health Board’s initial complaint response provided to Ms A’s sister fell well short of what the NHS Wales Duty of Candour requires. Although not in force at the time of the response, it was well known by the Health Board that the duty would be implemented and it should have responded to the complaint with openness and honesty with a direct input from clinicians involved in Ms A’s care.

“The evidence I have found shows that Ms A was at times in pain, which was not only distressing for her, but for her family as well. It concerns me that Ms A would likely have been very frightened when alone in hospital without family present, and experiencing pain. Additionally, the lack of record keeping in relation to Ms A’s seizures is not only dangerous, but also represents a poor level of care.

I upheld this complaint as I consider these shortcomings represent a serious service failure. The standard of care Ms A received fell very short of the required standard. The Equality Act requires healthcare providers to make reasonable adjustments for disabled people to ensure they are not disadvantaged when accessing healthcare. This did not happen in Ms A’s case, and she received a poor standard of care because of her learning disabilities.”

Commenting on the report, Public Services Ombudsman for Wales, Michelle Morris, said:

The Ombudsman’s Recommendations

The Ombudsman made several recommendations to the Health Board, including:

  • Apologising to Ms D
  • Reviewing:
  1. care planning practices on the ward to ensure care plans are embedded into basic care;
  2. a sample of person-centred care plans to ensure they include any adjustments to meet a patient’s individual needs;
  3. the approach to pain assessment for people with learning disabilities to ensure adjustments and appropriate tools are used.
  • Implementing a regular ward audit of nursing documentation, to include care plans and seizure charts.
  • Providing training to ward staff in respect of mental capacity and best interest decision making.
  • Engaging with the social services departments of all local authorities within the Health Board’s area to implement a joint care pathway to ensure safe staffing levels when vulnerable people with additional needs are admitted from care/nursing homes.
  • Providing confirmation that its Patient Safety and Experience Committee will monitor compliance with ongoing actions to satisfy the Ombudsman’s recommendations.

Betsi Cadwaladr University Health Board has accepted the Ombudsman’s findings and conclusions and has agreed to implement these recommendations.