Today we publish a new Public Interest report highlighting significant shortcomings in the patient’s post-operative care, failures in the informed consent process and inadequate contract monitoring arrangements in place between Betsi Cadwalader University Health Board and Health Trusts in England.
The complaint
We launched an investigation after receiving a complaint from Ms A about the care she received from Betsi Cadwaladr University Health Board and Liverpool University Hospitals NHS Foundation Trust (“the English Trust”) which had been commissioned by the Health Board.
Ms A’s concerns included her management and care following surgery for her inflammatory bowel disease in 2019, whether she was properly consented for surgery in March 2022, as well as postoperative care and treatment, and the handling of her complaint. Whilst our role and remit covers Welsh NHS bodies, as the Health Board commissioned care from the English Trust, our investigation reviewed the care and treatment which Ms A received from the English Trust on behalf of the Health Board.
The findings
Our investigation found multiple failings across various aspects of Ms A’s treatment and care, including failings in colorectal care, and in relation to gynaecological referrals, investigations and treatment undertaken by another English Trust. This led to Ms A having persistent infection and ill health for nearly 3 years before she received surgical treatment in March 2022.
We found that Ms A did not give informed consent for this surgery – she only signed the consent form on the day of her surgery and there was no record of prior discussion with her of the possibility of her having a hysterectomy during the surgery. Although we cannot make definitive findings of a breach of human rights, this failure led to us highlighting that Ms A’s Article 8 rights (the right to respect for private and family life) were potentially engaged.
We were concerned that in its contract monitoring of the commissioned care, the Health Board’s focus and priority was on its financial reporting of the commissioned care and did not include an assessment of the quality of the care and treatment delivered.
“I am mindful of the profound injustice caused to Ms A as a result of the significant failings that have occurred in her case.
I am extremely concerned about the process by which Ms A gave her “consent” for the surgery in March 2022. The relevant guidance makes it clear that consent is not simply a matter of completing and signing a form. Instead, consent is a process which should begin well in advance of the day of the surgery and any discussions should be clearly and separately recorded as part of the consenting process. This did not happen here.
This sad case also highlighted the wholly inadequate contract monitoring arrangements in place at the Health Board. Public bodies must have robust governance arrangements and must ensure that patient safety and the monitoring of the quality of services is in place.
The Health Board’s failure to monitor patient safety and service quality led to it missing crucial opportunities to address poor performance. With more effective contract monitoring, many of these failings could have been prevented.”
Michelle Morris, the Public Services Ombudsman for Wales.
Our recommendations
We made the following recommendations, which the Health Board has accepted:
- apologise to Ms A and share the report with relevant Health Board members.
- request the English Trust to review Ms A’s case, remind clinicians of informed consent and their professional obligations, and share key learnings through a case study of this case.
- request the Trust’s Surgeon to reflect on the case and discuss improvements to her clinical practice at her next revalidation.
- seek written assurances from the Trust’s Chief Executive that clinical failings are being addressed and provide compliance evidence to us.
- Health Board to prioritise, complete and implement a Commissioning Assurance Framework which gives proper consideration to patient safety.