Mrs A complained about the care and treatment provided to her late husband, Mr B, in relation to a large bowel obstruction and sigmoid stricture. Following advice at an outpatient appointment in April 2024, Mr B opted for further investigations, rather than surgery. By the next appointment, his health had declined to the extent he was no longer fit for surgery. Mrs A said that, despite worsening symptoms, Mr B was not admitted to hospital for nutritional support, monitoring, or timely surgery. Mr B sadly passed away following an emergency admission and surgery in September 2024. Mrs A was dissatisfied with the Health Board’s complaint response.
The Health Board was unable to provide records relating to the relevant outpatient appointment. The Ombudsman found that this raised concerns about the Health Board’s record-keeping. As a result, if the Ombudsman were to investigate Mrs A’s complaint, it would be difficult to establish with any certainty what was discussed in order to decide whether appropriate advice was given. This caused uncertainty and an injustice for Mrs A. The Ombudsman decided to settle the complaint without investigation.
The Health Board agreed to, within 4 weeks, provide Mrs A with a written apology for the lack of clinical records in relation the relevant consultation and the fact that this has prevented the Ombudsman investigating the matter. It also agreed to, within 4 weeks, provide Mrs A with a further complaint response setting out the learning points identified and the action taken as a result.