Clinical treatment in hospital
Upheld in whole or in part
Non-public interest report issued: complaint upheld
Aneurin Bevan University Health Board
Mrs B complained about the care provided by the Health Board to her late father, Mr C, in relation to 2 hospital admissions in August and September 2021. Specifically, Mrs B complained that the level of communication with Mr C’s family was inappropriate during his admissions and Mr C was discharged too quickly following his first hospital admission. Mrs B also complained that Mr C’s ability to care for himself at home was not assessed adequately and that a care package should have been arranged prior to his discharge on 8 September. Finally, Mrs B was concerned she was not given enough warning about the seriousness of Mr C’s condition and she was not allowed to see him the day before he died.
The investigation found that the Health Board had communicated with Mr C’s family appropriately about his clinical condition and care, but had failed to do so adequately in respect of both the level of assistance he would need from them at home following discharge, and when any professional assistance would commence. The investigation also concluded that the Health Board had failed to adequately assess Mr C’s care needs prior to discharge and, had it done so, it was likely that a care package would have been arranged before he was allowed home. However, the decision to discharge Mr C home from hospital was clinically appropriate as he no longer required treatment in an acute hospital setting. The investigation identified staff could not have foreseen Mr C’s rapid deterioration or have informed Mrs B of the seriousness of his condition at an earlier stage. Finally, the decision not to allow Mrs B to visit Mr C the day before he died was appropriate because his death was unforeseen.
The Ombudsman partly upheld Mrs B’s complaint that the level of communication with Mr C’s family was inappropriate during his admissions and upheld her concern that Mr C’s ability to care for himself at home was not assessed adequately and that a care package should have been arranged. The Health Board agreed to the Ombudsman’s recommendations to apologise to Mrs B in writing, and to remind staff about the importance of communication with family intending to provide care to discharged patients and the need for formal, safe discharge meetings. The Health Board also agreed to carry out an audit of a sample of discharge records on the ward. The Ombudsman did not uphold Mrs B’s complaints that Mr C was discharged too quickly nor that she was not given enough warning about the seriousness of Mr C’s condition and was not allowed to see him.