Mrs B complained about the care and treatment provided to her late mother, Mrs C. Specifically whether opportunities were missed to prescribe Mrs C insulin prior to her discharge from hospital and whether Ms C’s discharge from hospital was clinically appropriate and communicated appropriately.
The Ombudsman found that Mrs C should have been referred for further consideration of treatment for diabetes before she was discharged from hospital. Whilst Mrs C’s discharge from hospital was clinically appropriate, aftercare and follow-up in respect of diabetes and how this was communicated was not. These failures have left Mrs B with lasting uncertainty about what the outcome may have been had they not occurred, which is an injustice to her. Whilst not an issue identified for investigation, the Ombudsman also had concerns about the complaint response Mrs B received, as it was not recorded that the Health Board considered its obligations under the Duty of Candor. This is an injustice to Mrs B who did not receive information she was entitled to.
The Ombudsman sought and gained the Health Board’s agreement to apologise to Mrs B for the failings identified during this investigation and to ensure that clinicians involved in Mrs C’s care were familiar with the diabetes referral process and to remind them of the importance of keeping accurate and sufficiently detailed records.
It also agreed to provide refresher training to staff involved in investigating Mrs B’s complaint on the Duty of Candour and to reflect on why the consideration that the Duty of Candour may be engaged was not recorded.
The Health Board also agreed to review the role of the Diabetes Team in supporting hospital discharge and to share the investigation report internally for wider reflection and learning.