Mr A complained that while his mother, Mrs A, was admitted to hospital following a fall in May 2017, the Health Board failed to adequately assess and treat her symptoms of slurred speech, lethargy and fits, and that it incorrectly administered an antidote for a morphine overdose. He also complained that the Health Board failed to deal with his safeguarding concerns appropriately, particularly in relation to bruising to Mrs A’s elbow. He further complained that the Health Board did not deal with his formal complaint reasonably and had failed to provide him with information he had requested.

The Health Board had lost Mrs A’s health records for a significant period of her care. However, Mr A had already obtained a copy, which the Ombudsman was able to use to inform his investigation and findings.

The Ombudsman found that the Health Board failed to identify that Mrs A had acute kidney failure from the time she was admitted. In an attempt to control Mrs A’s back pain, she was prescribed pain relief at inappropriate levels (in the context of her kidney failure) and, even when she began to decline, this was not reviewed. The failure to monitor Mrs A’s medication and kidney function resulted in an acute kidney injury, which was probably preventable but was overlooked and, ultimately, precipitated her death. The prescription of the antidote was appropriate to counter the accumulation of opioid pain killers, which could not be filtered from Mrs A’s blood by her damaged kidneys. However, it was prescribed too late, which led to uncertainty about whether it might have had any effect if it had been prescribed sooner.

The Ombudsman accepted the ultimate outcome of the Safeguarding Investigations, which found that bruising to Mrs A’s arm had been caused by a manual handling accident when Mrs A was assisted to move up the bed. However, there had been significant delays in the reporting, processing, investigation and management of Mr A’s safeguarding concerns. Additionally, the Health Board had failed to process Mr A’s complaint in line with its complaints process, Putting Things Right (“PTR”), or keep him updated on progress of the investigation in line with that procedure.

The Health Board had identified, during the course of its own investigation, that Mr A’s complaint was not processed correctly, and that communication with him had been poor; it suggested to me that it would offer Mr A £750 in recognition of these failings. Following my investigation, the Health Board agreed to undertake the following actions:

Within one month of the date of this report:

(a) Provide a full and meaningful apology for all the failings identified in this report.

(b) Offer Mr A £750 as suggested by the Health Board for the complaint handling failure.

(c) Offer Mr A £500 for the failure to progress the two Safeguarding Referrals appropriately and £250 for the loss of Mrs A’s medical records.

(d) Offer Mr A further financial redress of £4,000, to reflect the failure to assess, diagnose and treat Mrs A’s condition and in recognition of the uncertainty as to whether remedial action might have prevented her death, as well as the distress caused to Mr A and his family in the manner of her death.

Within three months of the date of this report:

(e) Undertake a quality improvement project to consider the e-handover system for sharing information about a patient’s condition, medication, and any notable changes or deterioration in their presentation when they are moved in a planned move between wards. Where any shortcomings are identified an action plan should be put in place, to address them.

(f) All staff involved in this case should receive training on reporting and handling of injuries sustained during hospital admission, including receiving and processing of both Safeguarding Referrals and complaints raised under PTR and how each should be progressed. This should include guidance on the value of each of those processes, the importance of full and transparent record keeping,

and the consequences of carrying prejudices against patients and their families after any such report or Safeguarding Referral has been made.

(g) All staff involved in complaint handling on this case should be reminded of the role of the Concerns Team, which should ensure that investigations are concluded in a timely manner and that complainants are kept informed, in accordance with PTR.

(h) The Health Board should provide the Ombudsman with evidence that it has adequate arrangements in place for senior medical review on weekends and bank holidays for Geriatric Care.

Within six months of the date of this report:

(i) All doctors involved in this case and any other relevant clinicians should undergo further training, with particular reference to current NICE and professional guidelines, on recognition of sepsis and the risk of AKI, as well as drug dosing and toxicity in elderly patients and those with kidney disease.

(j) All doctors involved in this case should evidence a reasonable level of reflection upon the issues raised in this complaint, with particular reference to the themes set out in the analysis section of the report, including discussion of the matter at their next appraisal. The Health Board’s Medical Director should also review the report and consider whether any of the issues raised warrant referral of any relevant clinician to the GMC