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Clinical treatment in hospital : Cardiff and Vale University Health Board

Report date

22/11/2021

Subject

Clinical treatment in hospital

Outcome

Upheld in whole or in part

Case ref number

202003539

Report type

Public interest report issued: complaint upheld

Relevant body

Cardiff and Vale University Health Board

Mr D complained about the care and treatment he received at the University Hospital of Wales during a scheduled admission for surgery to remove the right side of the colon. Mr D complained that:

1. Clinicians suggested that his diseased colon was the result of either Crohn’s Disease (“CD”) or appendicitis but never provided him with a definitive diagnosis.

2. Clinicians were slow to identify that he suffered a post-operative bleed and required further, emergency surgery.

3. Clinicians were aware that he suffered with Asperger’s Syndrome (“AS”) but failed to make appropriate adjustments to how information was conveyed to him.

4. Nurses who conducted home visits to assist Mr D in managing a temporary stoma provided inappropriate, ill-fitting stoma bags and unreasonably declined to obtain alternatives; they also failed to adequately treat excoriated skin around the stoma.

The Ombudsman upheld complaint 1. The Health Board said that surgery was conducted on the presumption that Mr D had CD but that surgical findings later suggested complex chronic appendicitis. However, the Ombudsman, through his Surgical Adviser, found that Mr D’s pre-operative condition did not meet the threshold for surgery for either of these conditions. He also found (from the Surgeon’s intra-operative findings), that it should have been clear that there were no surgical grounds for removing even a limited amount of bowel tissue. The Adviser said that the risk to Mr D of performing surgery was not acceptable and that physicians should have employed a ‘watch and wait’ approach in which his condition would have settled without surgical treatment.

The Ombudsman upheld complaint 2. He found that there was no record of observations taken for several hours after Mr D’s surgery and that a number of factors suggested that early diagnosis of his post-operative bleed may have been delayed. Though the Ombudsman accepted that it was not clear whether earlier identification of Mr D’s deterioration would have changed the subsequent series of events, it nevertheless exposed him to substantial risk.

The Ombudsman also upheld complaint 3. He found that clinicians did not make reasonable adjustments to accommodate Mr D’s AS (and his difficulties with processing information). He also found that a specific request Mr D made to be seen by a mental health clinician was agreed but was not arranged.

The Ombudsman did not uphold complaint 4. He found that efforts made by Stoma Nurses to obtain and fit appropriate stoma bags (and to treat excoriated skin) were reasonable.

The Ombudsman recommended that Mr D be provided with a detailed apology and, in recognition of the avoidable trauma that he underwent and the distress that this report’s findings will give rise to, a redress payment of £10,000 (a sum reflecting the nature and degree of injustice to him). The Ombudsman further recommended that:

5. This report is shared with the Clinical Director responsible for the physicians involved in Mr D’s care and that its findings are directly discussed at their appraisals and revalidation.

6. These physicians undergo relevant training/revision in the management of CD and chronic appendicitis

7. This report is shared with the relevant Director of Nursing and directly discussed with those nurses involved in Mr D’s care.

8. That the nursing team revise/reflect on the importance of conducting and documenting post-operative observations and of preparing accurate and relevant care plans; and, that both hospital and community-based nursing staff receive relevant training in the care and management of patients with Asperger’s Syndrome.

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