Clinical treatment in hospital
Upheld in whole or in part
Non-public interest report issued: complaint upheld
Cwm Taf Morgannwg University Health Board
Mr A complained about the care given to his late father, Mr B, by Cwm Taf Morgannwg University Health Board. He complained that the Health Board had not treated Mr B appropriately when he attended the Emergency Department (“ED”) at the Royal Glamorgan Hospital, with a suspected stroke (a serious life-threatening condition that usually occurs when the blood supply to part of the brain is blocked), on 2 separate occasions. He said that it had not given Mr B aspirin or completed a computerised tomography(“CT”) scan (this uses X-rays and a computer to produce detailed images of the inside of the body) of his head on the first occasion, and that it had not completed such a scan within a reasonable time frame, or given Mr B aspirin, on the second. He complained that the Health Board had not monitored Mr B’s food and fluid intake, or his fluid output, properly after his admission to Prince Charles Hospital. He complained that the Health Board had not supervised Mr B appropriately immediately before Mr B fell. He also complained that the Health Board had not completed Mr B’s observations (measurements of an individual’s vital signs such as temperature), as required.
The Ombudsman found that a head CT scan and an aspirin prescription were not clinically indicated when Mr B first attended the ED and that the Health Board had treated him appropriately. He did not uphold this part of Mr A’s complaint. He found that the Health Board had not treated Mr B appropriately when he attended the ED for the second time because it had not considered the possibility that he had had transient ischaemic attacks (“mini strokes” caused by a temporary disruption in the brain’s blood supply) properly, had discharged him too soon and had not prescribed drugs, which make the blood less likely to clot, for him. He upheld this aspect of Mr A’s complaint. He found that the Health Board had monitored Mr B’s food intake appropriately. He noted that it had not been possible for the Health Board to measure Mr B’s fluid output accurately due to Mr B’s incontinence. He identified a fluid intake monitoring deficiency but could not clearly link that failing to an injustice to either Mr B or Mr A. He did not uphold this element of Mr A’s complaint. He found that the Health Board had not supervised Mr B appropriately immediately before he fell and upheld this part of Mr A’s complaint. He also found that the Health Board had not completed Mr B’s observations as required and upheld this aspect of Mr A’s complaint. He considered that the failings identified had caused Mr A, in terms of distress and uncertainty, an injustice. He also concluded that the Health Board had failed to pay due regard to the protection that Mr B, as a person living with dementia, was afforded by the Equality Act 2010.
The Ombudsman recommended that the Health Board should apologise to Mr A and pay him £1,000 in recognition of the significant distress and uncertainty caused by the failings identified. He asked the Health Board to review Mr B’s care and to discuss the diagnostic failings identified with relevant clinical staff. He recommended that it should obtain the written agreement of 2 Doctors to discuss Mr B’s care with their Appraisers. He also asked it to provide training, related to the care of patients with a cognitive impairment, for all relevant nursing staff and its Project Lead for Dementia. The Health Board agreed to implement these recommendations.