Clinical treatment in hospital
Upheld in whole or in part
Non-public interest report issued: complaint upheld
Aneurin Bevan University Health Board
Miss A complained about the care and treatment provided to her mother, Mrs B, by the Health Board between 23 June and 23 July 2021. We investigated whether Mrs B received appropriate nutritional care; whether Mrs B’s oral care and ongoing diarrhoea were appropriately managed; whether Mrs B’s prognosis was appropriately communicated to Mrs B and her family when she received her diagnosis of cancer and whether discharge planning and palliative care input was appropriate following Mrs B’s cancer diagnosis.
The Ombudsman found that Mrs B received appropriate nutritional and oral care and that communication about Mrs B’s diagnosis and prognosis was also appropriate. These complaints were not upheld.
The Ombudsman found that the majority of Mrs B’s care in relation to the management of her diarrhoea was appropriate. However, she found that there was a delay in administering loperamide (a medication which reduces bowel activity and diarrhoea). Earlier administration might have reduced the effect of diarrhoea and might have made Mrs B more comfortable. This was an injustice to Mrs B and this aspect of the complaint was upheld.
The Ombudsman found that whilst it was difficult to identify the best moment for transition from active to palliative care, on balance, a palliative care referral could have been considered sooner, which might have given Mrs B and her family reassurance and support. Even though Mrs B’s wish to return home was not achieved, this was not owing to inadequate discharge planning. Sadly, Mrs B’s rapid deterioration meant that she was too unwell to go home. The complaint was upheld to the extent that earlier palliative care input could have been considered.
The Health Board agreed to apologise to Miss A for the identified failings and share the report with relevant staff involved in Mrs B’s care for reflection and learning, in particular around the delay in administering loperamide and the timing of palliative care referrals.