Clinical treatment in hospital
Upheld in whole or in part
Non-public interest report issued: complaint upheld
Hywel Dda University Health Board
Mrs B complained that Hywel Dda University Health Board failed to provide appropriate care to her mother, Mrs T, during a hospital admission in April and May 2020, in relation to her fluid and nutritional needs, symptoms of nausea, vomiting and diarrhoea, skin care needs and low potassium levels. She complained that the Health Board had failed to ensure adequate and effective communication between ward teams and with Mrs T’s family. She also complained that the Health Board failed to investigate and handle her complaint properly.
The Ombudsman upheld the complaint about nutritional care on the basis that the nursing management of Mrs T’s nutrition needs was inconsistent. There was a failure to record evidence that appropriate actions were taken to encourage and support Mrs T at snack and meal times or to offer her food and drink in line with her preferences. Although the clinical impact of this was limited, these failings caused distress to Mrs T and her family which amounted to injustices. The Ombudsman found that the Health Board took appropriate actions to investigate and manage Mrs T’s nausea, vomiting and diarrhoea. He also found that the Health Board managed Mrs T’s skin care needs and low potassium levels appropriately. Accordingly, he did not uphold those elements of the complaint.
The Ombudsman partially upheld the complaint about communication between ward teams on the limited basis that poor communication within the nursing team impacted on continuity of care, which was an injustice to Mrs T. He also upheld the complaint about communication with the family, having regard to failures to provide adequate information about Mrs T’s declining condition. This meant the family were not adequately prepared for Mrs T’s sudden deterioration, which was a significant injustice. Finally, the Ombudsman identified shortcomings in the investigation and handling of Mrs B’s complaint but did not find that these were sufficiently serious to uphold that aspect of the complaint.
The Ombudsman noted that the Health Board had already produced an appropriate action plan to address many of the identified failings. The Health Board agreed to implement the Ombudsman’s recommendations which included apologising to Mrs B and her family and making a financial redress payment of £750 to Mrs B. It also agreed to review its monthly audits to ensure that care practices and provision have improved since the implementation of its action plan.