Clinical treatment in hospital
Upheld in whole or in part
Non-public interest report issued: complaint upheld
Aneurin Bevan University Health Board
Mrs A complained about her late husband’s management and care during his inpatient admission to the Royal Gwent Hospital (“the Hospital”) in late December 2019. Her complaint centred on the failure to administer the medication brivaracetam (used to prevent or reduce the severity of seizures) and the effects this had on her husband. She was concerned that when it was re-introduced, the dosage was too high and contributed to his subsequent fall. She also had issues with her husband’s nursing care, and felt the nursing records had not reflected her husband being at the end of his life, meaning a hospice referral was not made by the Palliative Care Team. Finally, Mrs A was dissatisfied with the Health Board’s handling of her complaint and the robustness of its complaint response.
The Ombudsman concluded that there was a clear failure to administer brivaracetam to Mr A, an essential medication for the management of his seizures. Administratively, the fact that the Health Board’s medication policy was not followed, meant the situation continued for longer than it might have. Despite this, the Ombudsman was satisfied that clinically Mr A’s outcome was not affected and that the confusion he experienced both before and after brivaracetam was re-introduced was primarily indicative of the progression of Mr A’s brain tumour. The Ombudsman found that the administration failings had caused Mrs A an injustice, since it added to Mrs A’s anxiety and concerns over her husband’s management at a difficult time for the family. To that limited extent the Ombudsman upheld this part of Mrs A’s complaint. In terms of wider care, while the Ombudsman concluded that the nursing care Mr A received was broadly reasonable and appropriate, nevertheless, the investigation identified episodes of care (for example around Mr A’s falls management including documentation, and an occasion where Mr A’s incontinence hygiene needs were delayed), where deficiencies occurred. To that limited extent these parts of Mrs A’s complaint were upheld. The Ombudsman also found shortcomings in the complaint handling process led to missed opportunities to learn from Mrs A’s complaint, and she upheld this part of Mrs A’s complaint. As the Ombudsman was satisfied that Mr A was appropriately placed in a nursing home she did not uphold this aspect of Mrs A’s complaint.
The Ombudsman’s recommendations included the Health Board apologising to Mrs A for the failings identified and reviewing the robustness of processes for the triggering of falls assessments, as well as engaging in wider learning around the falls assessments.