Clinical treatment in hospital
Upheld in whole or in part
Non-public interest report issued: complaint upheld
Betsi Cadwaladr University Health Board
Mrs X’s complaint related to the care and treatment that her late husband, Mr X, received during his admission to Glan Clwyd Hospital in March 2020. Specifically, Mrs X complained about the length of time that her husband was kept in an ambulance, and later in a corridor, following his arrival at the Emergency Department (“ED”) despite being suspected of having sepsis, as well as about the care and treatment that he received when he was then admitted onto a ward. In addition, Mrs X raised concerns that her husband’s oxygen supply was inappropriately removed while he was on this ward. After her husband was transferred to the Intensive Care Unit (“ICU”), Mrs X complained that the decision to turnoff his ventilator was inappropriate and premature, and that the Health Board failed to reattach his ventilator when his condition had not deteriorated after several hours of it being withdrawn. Mrs X also complained about the appropriateness of the sedative and analgesic drugs that her husband was prescribed and said that the Health Board did not give sufficient consideration to her family’s wishes nor allow any input into decisions about Mr X’s care and treatment. Lastly, Mrs X complained that nursing staff inappropriately removed her husband’s wedding ring after his death and that a subsequent letter about collecting his belongings was incorrectly addressed to him.
The Ombudsman concluded that the decision to withdraw active treatment was a reasonable one as, sadly, Mr X’s condition had deteriorated despite receiving appropriate intensive care treatment and further treatment was considered to be futile. The Ombudsman also concluded that it would not have been appropriate to have restarted active treatment once it had been stopped. Furthermore, the investigation found that the drugs prescribed to Mr X during this time were appropriate, and that appropriate discussions in relation to his care and treatment had taken place with his family. As a result, the Ombudsman did not uphold these complaints. The Ombudsman also did not uphold Mrs X’s complaint relating to the ED as, whilst it was clear that the ED was crowded at the time of her husband’s admission, Mr X nevertheless received appropriate care for sepsis. However, the Ombudsman found that Mr X should have subsequently been treated on a general medical or respiratory ward, and have been under the care of the Respiratory team. This had implications on the care that he received in terms of when investigations were requested and in that he should have been started on antiviral drugs while on the ward. The Ombudsman found that, although it was not possible to say for certain whether the outcome would have ultimately been different, Mr X’s chances of survival, in general terms, would have been better had he been seen by the Respiratory team and ICU clinicians, and appropriate treatment started, sooner. The Ombudsman considered the uncertainty created by whether the situation could have been different to amount to a significant injustice to Mrs X and so upheld this complaint. The Ombudsman also concluded that, on the balance of probabilities, Mr X’s oxygen had been inappropriately removed for a period of time while on the ward. In addition, whilst it was not unreasonable that nursing staff removed Mr X’s wedding ring after his death, the Health Board later sent a standard property letter which was incorrectly addressed to him. Therefore, the Ombudsman also upheld these complaints.
The Ombudsman recommended that the Health Board apologise to Mrs X for the failings that she had identified and that the report be shared with the medical staff involved in Mr X’s care on the ward for them to reflect on the case. She also recommended that, within 3 months of the final report, the Health Board reviews how patients are triaged from the ED or Acute Medical Unit to satisfy itself that referrals are made to the correct specialties. The Ombudsman also invited the Health Board to consider some additional improvement actions in relation to issues identified during the investigation.