· Produce an action plan based on the outcomes of the review and share this with my office and any clinical department for which the findings may be relevant.
The Ombudsman is pleased to note that in commenting on the draft of her report Cwm Taf Morgannwg UHB accepted and agreed to implement these recommendations.
Miss V complained about care and treatment provided to her cousin Ms F, by Cwm Taf Morgannwg University Health Board (“Cwm Taf Morgannwg UHB”) and Swansea Bay University Health Board (“Swansea Bay UHB”). Specifically, she was concerned that Cwm Taf Morgannwg UHB and Swansea Bay UHB (“the Health Boards”) missed opportunities to identify and treat the appendicitis that caused Ms F’s ruptured appendix.
The Ombudsman did not uphold the complaint against Swansea Bay UHB because she found that it was unlikely that Ms F had appendicitis during the time she was under Swansea Bay UHB’s care.
The Ombudsman upheld the complaint against Cwm Taf Morgannwg UHB. She found that Cwm Taf Morgannwg UHB had missed opportunities to identify and treat Ms F’s appendicitis during her attendances at the Ambulatory Emergency Surgical Unit at Princess of Wales Hospital on 17 and 20 July 2020.
The Ombudsman found that there was a failure to suspect appendicitis and admit Ms F to hospital on 17 July, taking into account her severe abdominal pain, unusually low blood pressure and blood test results which indicated the presence of a significant infection. There were also failures to prescribe antibiotics and arrange appropriate and timely investigations, including scans. Instead, Ms F was sent home and told to return for a review and further investigations on 20 July. This was a significant service failure.
The Ombudsman found that, after a scan on 20 July ruled out gallstones as a ]potential diagnosis, there was a further failure to admit Ms F to hospital for more investigations into the cause of her symptoms. She found that it was not appropriate to send Ms F home on 20 July with advice to return for review and further investigations 2 days later. This was another significant service failure. Sadly, Ms F did not return for further review, and she died at home on 1August 2020. The Ombudsman found, on the balance of probabilities, that if Cwm Taf Morgannwg UHB had provided appropriate care on 17 or 20 July, Ms F’s appendicitis would have been identified and treated, and her death would have been avoided.
The Ombudsman recommended that Cwm Taf Morgannwg UHB should within 1 month of this report:
· Provide a fulsome apology to Miss V and the family for the failures identified in this report and acknowledge that it missed opportunities to take steps which would likely have avoided Ms F’s death.
· Support Ms F’s family by offering details of solicitors who can provide Ms F’s family with confidential, independent legal advice to assess the contents and findings of this report in order that they receive appropriate financial compensation from Cwm Taf Morgannwg UHB, in recognition of the significant injustice caused to the family. Cwm Taf Morgannwg UHB should, within 1 month of the date of this report, ensure that it funds appropriate legal support to the family of Ms F to facilitate this.
· Share a copy of this report with the First and Second Consultants and provide evidence to the Ombudsman that they have reflected on the failings identified and how they can improve their practice in the future.
· Remind all clinicians working in ambulatory settings to be mindful when assessing patients with abdominal pain that a significant proportion of patients do not present with typical appendicitis.
And within 6 months of this report:
· Share a copy of this report with attendees of a forthcoming meeting of the Surgical Clinical Governance Team and provide evidence that the findings have been considered and discussed.
· Carry out a review of practice and procedure(“the review”) within the AESU and its other ambulatory settings to ensure that the failings identified in this report have been appropriately addressed, including (but not limited to) consideration of:
• How to ensure appropriate investigations (including CT scanning) are carried out for undiagnosed abdominal pain where there is evidence of infection/inflammation.
• How to ensure that antibiotics are appropriately prescribed where there is evidence of an infection/inflammation.
• How to ensure appropriate follow up, including repeat blood tests, and diagnostic work is completed prior to discharge when initial blood tests suggest infection/inflammation.
• How to ensure that patients who require more active management than can be provided in the AESU are appropriately escalated.
· Produce an action plan based on the outcomes of the review and share this with my office and any clinical department for which the findings may be relevant.
The Ombudsman is pleased to note that in commenting on the draft of her report Cwm Taf Morgannwg UHB accepted and agreed to implement these recommendations.