Mrs E complained that the Health Board’s treatment and care of her father, Mr D, fell below a reasonable standard. Specifically, Mrs E complained that Mr D was discharged on 12 October 2021 without a follow-up plan in place, which meant his pressure sore remained untreated. She also complained that the decision to carry out a barium swallow procedure (X-ray pictures taken after liquid containing a metallic compound is swallowed) was not reasonable, given Mr D had difficulties swallowing and was at risk of inhaling the liquid. Finally, she was concerned that a discussion about a Do Not Attempt Cardiopulmonary Resuscitation (“DNACPR”) decision was held with Mr D without the support of his family and without a diagnosis.
The investigation found that the Health Board failed to arrange a referral to the District Nursing (“DN”) team regarding Mr D’s pressure sores during the period of his discharge. Consequently, he suffered pain and discomfort, although the sores did not become worse. This point was upheld. The investigation also found that the administration of the barium swallow procedure was reasonable in itself, but it was unlikely the risks had been explained to Mr D, so he was unable to consent fully. This point was upheld to that extent. Finally, the investigation found that although the DNACPR decision was made without the involvement of Mr D’s family, the clinician did make several attempts to contact Mr D’s son. This point was not upheld.
The Ombudsman recommended that the Health Board should provide Mrs E with a written apology for the failings identified in this report. She was satisfied improvements had already been made regarding referrals to the DN team, but said the Health Board should review its arrangements for recording discussions with patients regarding radiological procedures and document its outcome.