Clinical treatment in hospital
Upheld in whole or in part
Non-public interest report issued: complaint upheld
Aneurin Bevan University Health Board
Mrs X complained about the care her late husband, Mr X, received from Aneurin Bevan University Health Board (“the Health Board”). She said the care planning for Mr X and the treatment he received after February 2020 was not reasonable or timely, he was not prescribed and/or given medication appropriately when he was an in-patient between July 2020 and December 2020, and he was discharged from hospital inappropriately in December 2020.
The Ombudsman’s investigation found that, following Mr X’s urgent cancer referral, he should have undergone a cystoscopy (an examination of the bladder using a thin tube with a light and camera on the end) under anaesthetic sooner than he did, and this likely resulted in Mr X’s bladder cancer taking longer to diagnose. This in turn meant that Mr X did not undergo chemotherapy sooner. Whilst it was not possible to be certain of the outcome, as a result Mr X did not undergo curative rather than palliative treatment. This was a service failure, and this uncertainty was an injustice to Mrs X and the Ombudsman upheld this part of the complaint.
With regard to Mr X not being prescribed and/or given medication appropriately when he was an in-patient between July 2020 and December 2020, the Ombudsman found that before and after Mr X’s laparotomy (an incision into the abdominal cavity to examine abdominal organs) in July 2020 he was not fully assessed in relation to the risk of blood clots and deep vein thrombosis (DVT) (including being given injections of an anticoagulant) which he developed days later. This was a service failure and caused Mr X discomfort and a prolonged stay in hospital. The Ombudsman upheld this part of the complaint.
The Ombudsman also had concerns about Mr X’s admission in December 2020 and the steps taken once again in relation to his assessment for blood clots. Whilst there were shortcomings, Mr X did not come to any harm, so the Ombudsman invited the Health Board to consider this admission as part of its reflection in relation to Mr X’s July admission.
Finally, the Ombudsman found that Mr X’s discharge from hospital in December 2020 was inappropriate and his dignity had not been considered: he arrived home in just a pyjama top and a towel around his waist, and the nephrostomy tubes (a catheter inserted through the skin into a kidney to allow urine diversion) in his back were loose. This was an injustice to Mr X and the Ombudsman also upheld this part of the complaint.
The Ombudsman recommended that the Health Board apologise to Mrs X for the failings identified, make a redress payment of £1,000 in recognition of the distress caused by the delay in diagnosing Mr X’s cancer and Mr X suffering DVT, share the report with all urology staff and the staff involved in Mr X’s laparotomy to ensure lessons are learnt, and carry out a serious incident review into Mr X’s DVT diagnosis which should be shared with Mrs X and the Ombudsman.
The Health Board agreed to all the recommendations.