Clinical treatment in hospital
Upheld in whole or in part
Public interest report issued: complaint upheld
Cardiff and Vale University Health Board
Miss X complained about the care and treatment her late father, Mr Y, received at University Hospital of Wales (“the Hospital”) in March 2020. He went to the Emergency Department (“the ED”) but was sent home. Two days later, he was admitted to the Hospital but sadly died a few days later having had emergency surgery.
The Ombudsman investigated whether Cardiff and Vale University Health Board:
• inappropriately discharged Mr Y from the ED
• failed to diagnose a bowel obstruction/strangulated hernia sooner and whether this impacted on his death
• failed to follow the correct do not attempt cardiopulmonary resuscitation process (“DNACPR” – where the heart or breathing stop, and the healthcare team decide not to try to re-start them).
The Ombudsman found that Mr Y was inappropriately discharged from the ED as a result of several shortcomings in the approach to his care. These included a failure to adequately assess his clinical history and new symptoms. The Health Board did not take enough information about Mr Y’s bladder symptoms, constipation and new large groin lump. These symptoms pointed to an obstructed hernia which needed treatment, but Mr Y was discharged without adequate assessment. Further assessment and admission at this time might have changed the outcome for him. This complaint was upheld.
Mr Y was admitted to the Hospital 2 days later. The Ombudsman found that his symptoms at this time were typical of a strangulated hernia with bowel obstruction, and this should have been recognised. Failure to do so led to a delay in Mr Y undergoing surgery which meant that his condition got worse. There were missed opportunities to repeat an abdominal X-ray and to carry out a CT scan sooner. The CT scan led to the diagnosis of an obstruction from the hernia. This diagnosis resulted in emergency surgery.
Had Mr Y been appropriately and urgently investigated and diagnosed on the day he was admitted, and undergone surgery sooner, his chances of survival would have been improved.
Mr Y was very ill following surgery, but he was not moved to the Intensive Care Unit (“ICU”). The decision that he would not benefit from this reduced his chances of survival. Had the clinical failings not occurred, and had Mr Y received ICU care following surgery, his deterioration and death might have been prevented. This complaint was upheld.
The Ombudsman was satisfied that the DNACPR decision was clinically justified. There was a record that this was discussed with the family. This complaint was not upheld.
In reaching her findings, the Ombudsman took account of the impact of the COVID-19 pandemic, which was beginning at the time Mr Y was admitted. This was creating extreme pressure for the Hospital staff. Even so, Mr Y was an emergency case and he did not receive the standard of care he should have.
The Ombudsman made a number of recommendations, which the Health Board accepted, including an apology and carrying out a case review to discuss assessment and diagnosis of strangulated hernias.