Mrs W complained about the care provided to her husband, Mr W, by Abertawe Bro Morgannwg University Health Board, following his oesophageal (relating to the food pipe between the throat and stomach) cancer surgery in February 2018. Mrs W said that Mr W never really recovered after his surgery; he struggled to eat and became emaciated, immobile, incontinent and depressed. Although palliative support was eventually arranged, this was only arranged just 2 weeks before Mr W died in September 2018.

The Ombudsman found that Mr W should have been given psychosocial support and specialist dietetic support before, during and after his surgery. He was unable to reach any conclusions about whether the frequency and standard of telephone support offered by a Specialist Nurse was clinically appropriate because no records were maintained. During the same period, Mrs W also approached a charity for support and wrote twice to the Health Board to request contact, explaining that Mr W was very unwell, rapidly losing weight and struggling to eat. In addition, a Dietician identified that Mr W was malnourished and lost 19% of his bodyweight.  No action was taken by the Health Board until Mrs W escalated her concerns to the NHS Wales Chief Executive, which should not have been necessary in light of Mr W’s prognosis and his deteriorating condition. The Ombudsman therefore concluded that there was no evidence that the Health Board provided adequate and appropriate post-discharge care and support to Mr W and that it had failed to deal with Mrs W’s requests for contact and support promptly.

He also found that Mr W and his wife were not advised on symptoms of recurrence or informed of Mr W’s prognosis after an analysis of the tissue removed during his surgery indicated that Mr W’s cancer had not been fully removed. There was no evidence that Mr and Mrs W were told of the high likelihood that Mr W’s cancer would recur and that, if it did, it would probably be systemic. Therefore, the Ombudsman concluded that the Health Board failed to keep Mrs and Mr W fully informed about Mr W’s condition, his prognosis and what to expect. The evidence in this case and in previous cases considered suggested that this failure was the result of a systemic issue relating to full and appropriate communication with patients, across the Health Board area.

The Ombudsman also found that, whilst Mr W’s terminal diagnosis was not apparent until his symptoms recurred, palliative care should have been offered once the outcome of the surgery, and Mr W’s poor prognosis, was known. The failure to do so meant that Mr and Mrs W were unable to access appropriate support and review promptly when Mr W’s symptoms did recur. As a result, the Ombudsman found that the Health Board failed to provide suitable end-of-life care to Mr W.

After the events leading to this complaint, changes took place to NHS provision in the local government area of Bridgend, which was transferred from the former Abertawe Bro Morgannwg University Health Board (re-named Swansea Bay University Health Board) to the former Cwm Taf University Health Board (re-named Cwm Taf Morgannwg University Health Board). Swansea Bay and Cwm Taf Morgannwg agreed to implement the Ombudsman’s recommendations respectively.

The Ombudsman recommended that, within 1 month of the date of this report, both Swansea Bay and Cwm Taf Morgannwg should:

(a) Provide an apology to Mrs W for the shortcomings identified in this report.

(b) Share this report with all staff throughout the relevant service areas, for them to reflect on the findings and conclusions.

He also recommended that, within 3 months of the date of this report, both Swansea Bay and Cwm Taf Morgannwg should:

(c) Review current practice on the recording of telephone support offered by the Specialist Nurse Service, to ensure that it is compliant with the NMC Code and standards on record keeping and remind all relevant staff of those standards.

(d) Conduct a random sampling Patient Opinion Survey to establish an understanding of patients’ experiences of UGI cancer care. Repeat this survey a year later to establish whether there has been any improvement and, if any issues around communications are identified as prevailing, take further steps to address them.

Further, he recommended that, within 6 months of the date of this report both Swansea Bay and Cwm Taf Morgannwg should:

(e) Ensure that the first Surgeon, the second Surgeon, the Oncologist and the Specialist Nurse consider and reflect on my findings as part of their regular supervision.

(f) Implement compulsory training for all doctors and nurses treating and managing patients with gastro-intestinal cancer, covering advanced communication skills and the need for patient involvement in care, including exploring patients’ expectations and values around their personal diagnosis and prognosis, as well as the human rights issues identified in this case.

(g) Take steps to ensure that patients with upper GI cancer have access to nutritional assessment, tailored specialist dietetic support and psychosocial support, in line with the NICE guidance.

Finally, the Ombudsman recommended that, within 9 months of the date of this report:

(h) Swansea Bay should consider the care in this case through a process akin to that provided in the Complaints Regulations, to decide whether there is any qualifying liability arising from any harm that arose from any breach in the Health Board’s duty of care as a result of the failings identified.

(i) Within 6 months of reminding relevant staff of the NMC standard of record keeping, both Swansea Bay and Cwm Taf Morgannwg should conduct an audit of a reasonable sample of Specialist Nurse records in the service, to determine the standard of compliance with NMC Code and take action to address any shortcomings.