Clinical treatment in hospital
Upheld in whole or in part
Non-public interest report issued: complaint upheld
Cwm Taf Morgannwg University Health Board
Ms A complained about the care and treatment provided to her mother, Mrs B, by Cwm Taf Morgannwg University Health Board (“the Health Board”). Specifically, Ms A said that Mrs B was prescribed inappropriate medication on a number of occasions, that the Health Board did not adequately assess or treat the causes of Mrs B’s confusion and that it did not address Mrs B’s deterioration from 7 June 2021 onwards. Ms A also complained that the Health Board did not ensure that Mrs B received adequate food and fluids and these records were not kept to a reasonable standard, that staff did not advise family members that Mrs B was deteriorating in time for them to be with her when she died and the Health Board’s explanation of who was at her bedside was contradictory, and that it was inappropriate for Mrs B to be transferred between hospitals on 13 May 2021 given that she was diagnosed with pneumonia that day and her condition had deteriorated. Finally, she said the Health Board did not keep track of Mrs B’s personal items between transfers.
The investigation found that the care and treatment provided to Mrs B by the Health Board fell below expected standards. This is because medication was administered inappropriately and it did not assess Mrs B’s delirium adequately, which led to missed opportunities to take further action. It also failed to escalate Mrs B’s deterioration on a couple of occasions and did not monitor Mrs B’s food and nutrition adequately. Finally, the Health Board did not keep track of Mrs B’s personal items between transfers. The Ombudsman therefore upheld these elements of the complaint. However, the investigation did not find that staff failed to advise family members of Mrs B’s deterioration and did not agree that it was inappropriate for Mrs B to be transferred between hospitals on 13 May 2021. These aspects were not upheld.
The Health Board agreed to the Ombudsman’s recommendations to apologise to Ms A for the failures identified in this report and for her time and trouble in bringing her complaint, and to remind nursing staff at the First Hospital about the importance of documenting information regarding intolerances or allergies to medication and of quickly escalating any concerns. The Health Board also agreed to remind nursing staff at the Second Hospital about the correct method of calculation for the NEWS process and the importance of appropriately escalating care. The Health Board agreed to remind nursing staff at both the First and Second Hospital of the expected standards for completing nutritional risk assessments and associated documentation and that documents relating to patients’ belongings should be completed thoroughly and consistently. Finally, the Health Board agreed to complete an audit of a sample of similar cases across all 3 hospitals within their authority to assess whether there is a wider problem regarding the assessment of delirium and to develop a consistent approach for structured assessment. It also agreed to conduct teaching sessions for learning on screening, recognition of delirium, common causes and management to relevant staff.