Report Date

11/19/2021

Case Against

Betsi Cadwaladr University Health Board

Subject

Clinical treatment in hospital

Case Reference Number

202002739

Outcome

Upheld in whole or in part

Mrs X’s complaint relates to the care and treatment that her late husband, Mr X, received from Betsi Cadwaladr University Health Board during his admissions to Glan Clwyd Hospital (“the First Hospital”) and Llandudno Hospital (“the Second Hospital”) in early 2020. Specifically, she complained that the Health Board did not properly monitor her husband after he had been given morphine in the Emergency Department, that it failed to identify or treat her husband’s ongoing constipation, and that it failed to carry out a barium swallow and video fluoroscopy in a timely manner. Mrs X was also concerned that failings in her husband’s care and treatment, including a failure to recognise his deteriorating condition in general, potentially caused, or contributed to, his later bleed within the brain.

The Ombudsman concluded that it had been appropriate to give Mr X morphine and that the short, unresponsive, episode that he experienced soon after (which itself could not have been predicted and was seemingly unavoidable) was quickly identified with the appropriate action subsequently taken to treat it. He also concluded that, given the barium swallow and video fluoroscopy would not have been likely to have made any significant difference to the management of Mr X’s longstanding swallowing problems, the length of time between Mr X being assessed on 2 February and the tests being scheduled to take place on 10 February was not unreasonable. Lastly, the investigation found that Mr X’s past medical history of arterial disease was a predisposing factor in the bleed that he sadly experienced. The care and treatment that Mr X had received during his admissions did not contribute to, or in any way cause, the bleed. As a result, the Ombudsman did not uphold these complaints. However, the Ombudsman also found that there was no evidence within the records of any evaluation of whether the laxative that had been prescribed to Mr X during his first admission was effective. Mrs X had also said that her husband had to perform a manual evacuation of his bowels after he was discharged from the Second Hospital. In light of these factors, the Ombudsman concluded that Mr X’s ongoing constipation was not properly identified and treated prior to his discharge home, and upheld the complaint.

The Ombudsman recommended that, within 1 month, the Health Board apologises to Mrs X and reminds all relevant staff of the importance of evaluating and documenting the effectiveness of prescribed medications (such as short term laxatives) during inpatient admissions. The Health Board agreed to implement the recommendations.