New Public Interest report issued by Public Services Ombudsman for Wales finds that, had Mrs K been treated appropriately at the outset by Betsi Cadwaladr University Health Board, her acute pancreatitis would have been treated successfully and on balance, her deterioration and death might have been prevented.
The Complaint
The Ombudsman launched an investigation after Mrs L complained about the care and treatment her late mother, Mrs K, received from Betsi Cadwaladr University Health Board between January 2021 and her death on 31 January 2022 from biliary sepsis.
What the Ombudsman found
The Ombudsman concluded that if Mrs K had been treated appropriately at the outset, her pancreatitis would have been treated successfully and her deterioration and death may have been prevented. The Ombudsman also found little to no evidence that the seriousness of Mrs K’s condition was appropriately communicated in October to her and her family either before or after treatment.
The Ombudsman also found that the Health Board’s response to the complaint lacked candour and there had been a further lack of objective reflection during the Ombudsman’s investigation when the Health Board had sight of the Ombudsman’s Clinical Advice.
“The failure to identify Mrs K’s gallstones in January 2021 was an unacceptable service failure which caused Mrs K and her family a continued and grave injustice.
I am saddened to conclude that, had Mrs K been treated appropriately at the outset, her acute pancreatitis would have been treated successfully and on balance, her deterioration and death might have been prevented.
I am deeply concerned at the Health Board’s seeming lack of candour in its complaint response to Mrs L, and its lack of objective reflection by its clinicians during my investigation in that it continued to fail to identify and acknowledge failings in Mrs K’s care.
I am mindful that the episode of care happened during a time when there were still some restrictions in place as a result of the COVID-19 pandemic. However, having taken full account of the potential impact of those restrictions, I have been that reassured that, even with the COVID-19 restrictions on endoscopy services, Mrs K would have accessed appropriate treatment within a few weeks.”
Commenting on the report, Public Services Ombudsman for Wales, Michelle Morris, said:
Recommendation
The Ombudsman recommended that the Health Board should:
- Provide Mrs L with a full apology from the Chief Executive
- Pay Mrs L £4,000
- Review this case, in line with its legal requirements under the Duty of Candour, to determine how Mrs K’s presentation in January 2021 was misdiagnosed owing to inadequate assessment/imaging. The Health Board to report its findings to its Quality and Patient Safety Committee and in its Annual Report on the Duty of Candour.
- Share the Ombudsman’s report with the Clinical Director responsible for the consultants involved in Mrs K’s care so that its findings are reflected upon and discussed with those consultants.
- Review its handling of Mrs L’s complaint in line with the Duty of Candour
Betsi Cadwaladr University Health Board has accepted the Ombudsman’s findings and conclusions and has agreed to implement these recommendations.