Clinical treatment in hospital
Upheld in whole or in part
Non-public interest report issued: complaint upheld
Betsi Cadwaladr University Health Board
Mr K complained about the care and treatment provided to his late mother (“Mrs L”) by Betsi Cadwaladr University Health Board (“the Health Board”) and about its response to his concerns.
The Ombudsman upheld Mr K’s complaint that the Health Board failed to respond to his complaint adequately and in a timely manner. The investigation found that complaint handling failures caused an unacceptable delay of 4 years in providing a complaint response and that the Health Board had failed to address some of Mr K’s key concerns. This caused injustice to Mr K because of the resulting prolonged uncertainty and significant inconvenience he experienced chasing up his complaint. The Ombudsman upheld Mr K’s complaint that Mrs L had not received adequate dementia care at Chirk Hospital but noted that the Health Board had accepted failings and taken appropriate remedial action. The Ombudsman upheld Mr K’s complaint that the Health Board had missed opportunities to acknowledge failings in the NHS Continuing Health Care assessment process. Although the Health Board had repeated its offer of a retrospective review, this would have happened much sooner if it had handled Mr K’s concerns appropriately.
The investigation found that the management of Mrs L’s skin care needs at Chirk Hospital was appropriate. However, the Ombudsman upheld the aspect of this complaint relating to the district nursing service. The investigation found that there had been failures in the way district nurses communicated with each other, the family and care home staff, and in the documentation of assessments. This was a significant injustice to Mrs L because the failings may have contributed to deterioration in the condition of her ankle wound, pressure damage to her left hip and a failure to control associated pain.
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The Ombudsman noted that the Health Board had reviewed its processes and taken appropriate remedial actions in response to the failings identified. The investigation found that the management of Mrs L’s skin care needs at Wrexham Maelor Hospital was appropriate. Accordingly, the Ombudsman did not uphold this complaint.
The Ombudsman recommended that within 1 month, the Health Board should apologise to Mr K and make a payment to him of £2,025 in respect of complaint handling failures and the impact of the district nursing failures. He also recommended that the Health Board should, within 4 months, carry out a review of its complaints management policies and begin using the investigation report as a case study for internal complaint handling training. The Health Board agreed to these recommendations.