Mr C complained about the standard of nutritional care provided to his late father, Mr D, during his admission to Ysbyty Ystrad Fawr. The Ombudsman’s investigation considered whether:
• The Health Board took appropriate action to assess and address Mr D’s nutritional care needs.
• There were appropriate and timely referrals for review by Speech and Language Therapy, ENT and/or dietetics to address Mr D’s identified nutritional needs.
The Ombudsman’s investigation found that there was a delay of 1 week in referring Mr D for dietetic review. This would have enabled assessment of the adequacy of Mr D’s nutritional intake, and earlier consideration of non-oral feeding. It was difficult to conclude that an earlier referral for dietetic review would have altered the outcome for Mr D. However, the Ombudsman accepted that the family’s concern about Mr D’s nutritional management and the resulting uncertainty about whether earlier dietetic review may have improved the outcome for Mr D was itself an injustice. The complaint was therefore upheld to that limited extent.
The Health Board agreed to provide an apology to Mr D’s family, and it produced an action plan to promote improvement in nutritional care and monitoring.