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Clinical treatment in hospital : Cwm Taf Morgannwg University Health Board

Report date

12/07/2021

Subject

Clinical treatment in hospital

Outcome

Upheld in whole or in part

Case ref number

202001285

Report type

Public interest report issued: complaint upheld

Relevant body

Cwm Taf Morgannwg University Health Board

Mr X complained about the care and treatment provided to his wife, Mrs X (who had been diagnosed with cancer 3 months earlier) at Prince Charles Hospital (“the Hospital”) Emergency Department (“ED”) on 16 and 17 December 2019 when she was admitted with a possible infection. Mr X was concerned that due to staffing levels and the high level of patients at the ED, Mrs X’s care may have been compromised. Mr X believed that, had Mrs X received earlier diagnosis and treatment, there was a chance she may not have aspirated (where contents such as food, drink, saliva or vomit enter the lungs and is characterised by coughing, difficulty breathing, and shortness of breath). Mrs X sadly died on 17 December.
The investigation considered whether there was a delay in:
a) Diagnosing the reason for Mrs X’s admission.
b) Commencing treatment once a diagnosis had been reached.
c) Administering oxygen when Mrs X’s oxygen saturation levels were recorded as low.
d) Responding to Mrs X’s breathing difficulties which led to aspiration.

The Ombudsman found that there was a significant delay in diagnosing the reason for Mrs X’s admission. Despite a pre-alert call indicating that Mrs X possibly had sepsis (and the failure to recognise the significance of this), the Ombudsman found that the time taken to reach a diagnosis of pneumonia and commence correct treatment was alarming. There was a catalogue of failings that contributed to this delay, including lack of regular monitoring or appropriate escalation when investigation results and monitoring indicated significant clinical deterioration.
Once the diagnosis had been made, correct antibiotic treatment was commenced within the hour. However, Mrs X should have received antibiotic treatment within 1 hour of her admission to the ED, not within 1 hour of the diagnosis. This would have been in line with national clinical guidance. This had significant consequences for Mrs X. There was a delay of 15 hours before appropriate antibiotic treatment was started.

The Ombudsman considered that, on balance, Mrs X would have survived the admission had she received antibiotics within 1 hour of arrival at the ED. Whilst Mrs X’s family accept that her cancer diagnosis meant that she probably had less than a year to live, the identified shortcomings in clinical care meant that Mrs X, Mr X and their family were denied this precious time together. This engaged their Article 8 rights under the Human Rights Act 1998. The Ombudsman also found that there was a considerable delay in administering oxygen and, had Mrs X not encountered delays in diagnosis and treatment, and had she received appropriate monitoring and escalation of abnormal vital signs, it is possible that Mrs X would have been less likely to aspirate. The Ombudsman found that there was a series of failings which contributed overall to a very poor standard of care for Mrs X and denied her the opportunity of spending the little time she had left with her family. The Ombudsman was deeply saddened by this. He upheld all of the complaints.

In addition, the Ombudsman found that there were occasions during Mrs X’s admission when there were insufficient numbers of healthcare support workers on duty. Mr X’s impression of the ED as having insufficient staffing levels in relation to an exceptionally high number of patients, was supported by the Ombudsman’s professional adviser’s opinion that the ratio of staff to patients appeared to be unacceptably high. This meant that Mrs X could not be appropriately monitored in the corridor of the ED. This led the Ombudsman to the view that, on balance, the staffing situation at the ED, which was at extreme pressure escalation level, might have, on balance, contributed to the level of poor care Mrs X received. The pressure on the ED department during Mrs X’s admission and that fact that she was nursed in the corridor for almost 12 hours also compromised her dignity and impacted on the quality of the family’s remaining time with Mrs X.

Finally, whilst the Health Board belatedly carried out a root cause analysis investigation into Mrs X’s care; this was not done until after the Ombudsman commenced his investigation. The Health Board’s investigation identified the same shortcomings as the Ombudsman’s investigation. Had the Health Board carried out this action as soon as it received Mr X’s complaint, this may have resolved the complaint much sooner and provided Mr X with open and honest answers about what happened during Mrs X’s admission. As a result of its own investigation, the Health Board prepared an action plan to address the failings it identified. This limited the number of recommendations the Ombudsman made as they would be replicated. The Ombudsman made a number of additional recommendations to ensure that lessons were learnt and to ensure improvement in service delivery for patients. The Health Board accepted the recommendations in full which are to:
a) Provide a fulsome written apology to Mr X for the significant failings in his wife’s care and the distress caused to the family which meant that they were denied what little time they had left with Mrs X.
b) Arrange awareness training for all ED staff on the correct use of the NEWS chart and when escalation to the nurse in charge/doctor is required.
c) Arrange training for all ED staff on the recognition and management of suspected sepsis.d) Carry out an audit of a sample of patient ED records, including NEWS charts at the Hospital ED to ensure that these are being calculated correctly and that staff have escalated appropriately where indicated.
e) Create a standard operating procedure for the management of ASHICE patients (a hospital pre-alert for any patient whose clinical condition suggests special arrangements need to be made by the receiving hospital) within the ED Department.

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