Report Date

15/08/2024

Case Against

Aneurin Bevan University Health Board

Subject

Admissions/discharge and transfer procedures

Case Reference Number

202307487

Outcome

Upheld in whole or in part

Mrs C complained about care provided to her mother, Mrs D, by the Health Board. The Ombudsman considered whether Mrs D’s discharge from hospital on 12 February 2021, including planned aftercare and follow-up, was clinically appropriate.
The Ombudsman found that at the time Mrs D was discharged, her white blood cell count was still raised. However, her observations were stable and there were no acute changes to her condition. It was appropriate for her to have been discharged; she was to continue oral antibiotics and arrangements were made for her to have further outpatient investigations and blood tests. There was no requirement for the Health Board to have arranged any package of care for her, as she was self-caring in hospital and there was no reason to believe she would not continue to be so.
The Ombudsman found that it was appropriate that the medication Mrs D was receiving while she was in hospital, to reduce the risk of blood clots, was stopped before she was discharged from hospital. However, there was no evidence that Mrs D was advised of the importance of good hydration and leg exercises, as recommended by guidance. There was no way of knowing whether hydration and exercises alone would have prevented Mrs D suffering a pulmonary embolism (“PE” – a serious condition caused by a blood clot in the lungs). However, the fact this advice was not given to her meant she lost the opportunity to reduce the risk of this occurring, and this was an injustice to her. The Ombudsman therefore upheld the complaint to this extent.
The Health Board agreed to the Ombudsman’s recommendations to apologise to Mrs C, to pay her financial redress of £500, and to remind relevant clinicians to provide appropriate information prior to discharging patients at risk of PE.