Clinical treatment in hospital
Upheld in whole or in part
Public interest report issued: complaint upheld
Betsi Cadwaladr University Health Board
Mr D complained about the care and treatment that his late mother, Mrs M, received at Glan Clwyd Hospital and Llandudno General Hospital. He complained that:
Clinicians failed to adequately investigate and appropriately treat Mrs M’s symptoms of abdominal pain, gastro-intestinal upset and weight loss which she developed following bowel surgery.
Clinicians failed to accurately assess Mrs M’s frail condition and discharged her without appropriate home care support in place. This was subsequently provided by the Council but was inadequate and, within days, Mrs M was readmitted.
The decision to remove Mrs M’s nasogastric tubing led to further weight-loss and deterioration.
A secondary cause of Mrs M’s death – an ischaemic bowel, was not identified from scans or investigations conducted during her admissions.
The Health Board and the Council failed to coordinate their response to the complaint. The Council’s response was received 6 months after the response provided by the Health Board.
The Ombudsman upheld complaint1. He found that senior physicians at both hospitals (including the Colorectal MDT) failed to identify that Mrs M had developed a post-operative blockage in the small bowel (a small bowel obstruction – SBO). He found that, despite conspicuous radiological and clinical evidence pointing to this, physicians inappropriately excluded a physical cause for Mrs M’s symptoms and attributed her weight loss and aversion to eating to a ‘food phobia’. The Ombudsman could not definitively conclude that the failure to identify and treat the SBO meant that Mrs M’s death was preventable. This was because it was unclear whether she could have sustained further surgery, given her frail condition and comorbidities. The Ombudsman nevertheless considered this to be an alarming, systemic misdiagnosis and considered the uncertainty surrounding whether an opportunity to surgically intervene was lost, to be in itself, an injustice to Mrs M and her family.
The Ombudsman upheld complaint2. He found that the attempt to discharge Mrs M failed due to multiple shortcomings on the part of both the Health Board and the Council in relation to pre-discharge planning and to the post-discharge support Mrs M received.
The Ombudsman did not up hold complaint 3. He found that the nasogastric tube was appropriately managed and was removed at Mrs M’s request.
The Ombudsman upheld complaint4. He found that, although difficult to detect, ischaemia might have been prevent able had the clinical suspicion of an SBO been considered and pursued. However, the Ombudsman could not definitively conclude this because direct treatment of ischaemia would have rested on Mrs M being able to sustain surgery. As with complaint 1, the Ombudsman nevertheless considered that the uncertainty surrounding the question of whether an opportunity to conduct surgery was lost, amounted, in its own right, to a serious injustice to the family.
The Ombudsman upheld complaint 5. He found that there were complaint-handing failings on the part of both bodies.
The Ombudsman recommended that:
• Both bodies provide Mr D with fulsome written apologies for the failings identified in this report.
• Both bodies share the report with the irrespective Equalities Officers to facilitate training on the principles of human rights in the delivery of care.
• Each body makes a redress payment to the family of £250 in recognition of failings in complaint handling.
• The Health Board makes a redress payment of£5,000 to the family in recognition of the distress that the findings of this report will give rise to.
The Ombudsman additionally recommended that the Health Board:
Demonstrates that the report has been discussed with the physicians involved in Mrs M’s care and that the diagnostic failings are reflected upon at their appraisals and revalidation.
Evidences that these physicians have undergone training/revision in regard to: the diagnosis and treatment of SBOs; the theory and practice of the use of contrast media in CT scans and the clinical contexts in which the threshold for CT investigations should be lowered; the medical management of nutritional needs.
Demonstrates that the relevant nursing teams referred to in the report undergo revision of the Health Board’s Discharge Policy and are reminded of the importance of documenting actions, plans and developments surrounding the discharge process.
Both the Health Board and the Council accepted the findings and conclusions of the report and agreed to implement these recommendations.