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 aunt, Ms B, by Cwm Taf Morgannwg University Health Board (“the Health Board”) after her admission to hospital, with pelvic injuries, following a fall. He said that the Health Board failed to reassess the status of Ms B’s lung cancer after that admission, to manage her pain relief effectively, to respect her wishes when it transferred her from one hospital to another and to ensure that her fluid intake was sufficient. He also stated that it failed to inform him, or other family members, of the significant deterioration in Ms B’s condition or consult him about its Do Not Attempt Cardiopulmonary Resuscitation (“DNACPR” – cardiopulmonary resuscitation is emergency treatment that aims to restart the heart and breathing) decision.
The Ombudsman found that it had not been clinically necessary for the Health Board to reassess Ms B’s lung cancer after her admission to hospital. He did not uphold this part of Mr A’s complaint. He found that the Health Board’s management of Ms B’s pain relief was deficient. He upheld this aspect of Mr A’s complaint because this failing caused Ms B and Mr A distress. He also considered that the Health Board’s failure to investigate Ms B’s pelvic injuries further caused them uncertainty in terms of the exact cause of Ms B’s pain and the continued appropriateness of her management plan. He was satisfied that Ms B’s hospital transfer was clinically reasonable. However, he found that the Health Board’s management of that transfer was deficient because there was no evidence that it was discussed with Ms B before it took place. He partly upheld this element of Mr A’s complaint because this apparent omission caused Ms B potentially avoidable distress, anxiety and confusion. He found that the Health Board failed to ensure that Ms B’s fluid intake was sufficient. He upheld this part of Mr A’s complaint because this failing caused Mr A concern and uncertainty. He found that the Health Board’s communication with Mr A and other family members, about Ms B’s clinical condition, was lacking. He did not consider it reasonable to criticise the Health Board for not consulting Mr A about its DNACPR decision given its context. However, he found that better communication with Mr A and other family members, regarding Ms B’s clinical condition, would have facilitated a discussion about a DNACPR decision with them, and possibly Ms B, before the date on which that decision was taken. He partly upheld this aspect of Mr A’s complaint because the Health Board’s communication failings denied Mr A the opportunity to be involved in the discussion about the DNACPR decision and might not have enabled him to see Ms B shortly before her death.
The Ombudsman recommended that the Health Board should apologise to Mr A for the failings identified. He asked it to share his investigation report with relevant staff. He recommended that it should give relevant nursing staff pain management training. He also asked it to undertake an audit of nursing records to ensure that communication with patients and their families had improved. The Health Board agreed to implement these recommendations.