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Clinical treatment in hospital : Cwm Taf Morgannwg University Health Board

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Clinical treatment in hospital


Not Upheld

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Non-public interest report issued: complaint not upheld

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Cwm Taf Morgannwg University Health Board

Mrs Q complained about the care and treatment that her late husband, Mr Q, received at Prince Charles Hospital (“the Hospital”) for his condition of non-Hodgkin’s Lymphoma (“NHL”) and in regard to his subsequent admissions with COVID-19. Specifically, Mrs Q complained that:

• A specialist scan conducted on 27 January 2020 failed to collect a sufficient tissue sample and had to be repeated. This was traumatic for Mr Q and delayed his diagnosis.
• Mr Q was told that the second biopsy indicated a treatable and curable condition but this was later revised to a treatable but incurable condition. This mis-diagnosis was severely traumatising for Mr and Mrs Q and they were not provided with appropriate counselling or support.
• A further specialist scan, requested on 15 June 2020, was not completed and reported on until 14 August 2020. This adversely delayed Mr Q’s ongoing chemotherapy treatment.
• Despite being immuno-compromised and vulnerable, Emergency Department (“ED”) clinicians and a Consultant Haematologist declined to admit Mr Q when he tested positive for COVID-19 and again, when on 26 December 2020, his condition deteriorated.
• Mr Q was subsequently admitted as an emergency to the Hospital on 9 January 2021 with COVID-19 and pneumonia. However, he was prematurely discharged 2 days later without being reviewed by the Haematology Team. The management of his medication was left to his GP. Once home, he again deteriorated and required re-admission on 18 January 2021. This admission was also managed by his GP as the Haematology Team had declined to arrange this.
• While on the COVID-19 Respiratory Ward and following transfer to the Intensive Care Unit (“ICU”) (where sadly, he died on 4 February), Mr Q was not reviewed by the Haematology Team and during this time, no updates on his condition were provided to his family.

The Ombudsman’s investigation found:

• A second biopsy did not delay Mr Q’s NHL diagnosis.
• Mr Q was not mis-diagnosed at any point.
• There was no delay in Mr Q’s ongoing chemotherapy treatment due to a CT scan that was correctly scheduled.
• Despite Mr Q being COVID-19 positive, his symptoms and presentation did not indicate that he should be admitted to hospital.
• Mr Q was discharged appropriately as his condition had improved.
• The Haematology Team communicated appropriately with both the Respiratory Ward and ICU in managing Mr Q’s NHL while he was COVID-19 positive.
The Ombudsman did not uphold the complaint.