Clinical treatment in hospital
Upheld in whole or in part
Non-public interest report issued: complaint upheld
Betsi Cadwaladr University Health Board
Mr B and his daughter, Ms C, complained about the care and treatment provided to Mr B’s late wife, Mrs B, by Betsi Cadwaladr University Health Board during her admissions to Wrexham Maelor Hospital and Chirk Community Hospital between June and October 2021. Specifically, they complained that the Health Board failed to appropriately investigate Mrs B’s symptoms of stroke when she attended the Emergency Department (“ED”) on 17 June, and that, during a later admission, the Health Board failed to promptly identify and appropriately respond to her deterioration between 30 September and 5 October. Mr B and Ms C also complained that medical and nursing staff failed to adequately communicate with Mr B in relation to his wife’s diagnoses and condition. Lastly, they raised concerns that Mrs B was not given enough support by nursing staff with her food and fluid intake, which in particular led to her being burnt on 2 occasions by hot drinks.
Due to the Health Board having lost the paper records of Mrs B’s ED attendance on 17 June, the Ombudsman was unable to determine whether her symptoms were appropriately investigated and treated. The Ombudsman considered the loss of her records to be a serious failing and one which resulted in Mr B being left in doubt as to whether his wife had suffered a stroke. Accordingly, the complaint was upheld. The investigation also found that while appropriate action was taken when Mrs B was initially noted to be unwell on 1 October, there was a delay in transferring her back to Wrexham Maelor Hospital when she became more unwell on 2 October. After she was transferred, there was then a delay in the administration of antibiotics for suspected sepsis while in the ED. Although Mrs B already had a poor prognosis, the uncertainty caused by these delays in terms of whether these effected the overall outcome was a significant injustice to Mr B and Ms C, and the complaint was upheld. Furthermore, the investigation found that communication with Mr B regarding his wife’s diagnoses and condition was inadequate throughout her inpatient admissions. The investigation also found failings in the monitoring of Mrs B’s nutrition and fluid intake, and that whilst it was unclear whether these had an adverse effect on Mrs B, Mr B was left in doubt as to whether she received adequate food and nutrition. In addition, the Ombudsman concluded that the 2 incidents where Mrs B suffered burns from spilling hot drinks were avoidable, as there had been a failure by nursing staff to identify and manage the risks to her. As a result, these complaints were also upheld.
The Ombudsman recommended that the Health Board apologise to Mr B and Ms C for the failings identified by her investigation and offer a payment of £1000 to them in recognition of the distress and uncertainty caused by these failings. The Ombudsman also made a series of recommendations for the Health Board to implement, including that it takes action to ensure that nursing staff are trained and competent in escalation when a patient’s physiological observations put them at a high risk of deterioration, and that it carries out audits on the completion of the NHS Wales Adult Risk Screening Tool and fluid charts.