Clinical treatment in hospital
Upheld in whole or in part
Non-public interest report issued: complaint upheld
Hywel Dda University Health Board
The Ombudsman investigated Mr L’s complaint that Hywel Dda University Health Board (“the First Health Board”) and Swansea Bay University Health Board (“the Second Health Board”) failed to monitor his late wife, Mrs L’s, bowel problems appropriately; to fully investigate and treat the cause of her raised infection markers promptly; and to refer her for another scan promptly and appropriately when her symptoms escalated. The investigation also considered whether the First Health Board monitored Mrs L’s arterial cannula (a thin tube inserted into the artery to enable continuous measuring of blood pressure) appropriately and took action promptly to address ischaemia (restriction of blood supply to tissue) when it developed during her final hospital admission.
The Ombudsman found that Mrs L’s bowel problems were investigated and treated appropriately, and that in the circumstances, follow up monitoring was not necessary after her initial discharge from hospital. There were several possible reasons for Mrs L’s inflammatory markers being raised, and the Ombudsman did not identify any failings by the First and Second Health Boards in investigating and treating the cause. She also found that when Mrs L’s symptoms escalated she was promptly and appropriately referred for a scan. The Ombudsman did not uphold these aspects of the complaint.
The Ombudsman found that it was necessary for Mrs L to be fitted with an arterial cannula when she was undergoing major surgery, and that when her ischaemic hand was brought to the attention of medical staff, appropriate action was taken. However, the First Health Board’s monitoring of the arterial cannula fell short of the expected requirements. Whilst the Ombudsman could not say with any certainty that Mrs L’s ischaemic hand would have come to light earlier if it had been appropriately monitored, it is possible that it would. The Ombudsman considered it likely, on the balance of probabilities, that it was Mr L who brought the issue to the attention of nursing staff. Whilst the Ombudsman did not find that the shortcomings in monitoring had an adverse impact on the outcome, she considered it likely that they resulted in distress and anxiety to both Mr and Mrs L. To this extent, the Ombudsman upheld the complaint
The Ombudsman recommended that the First Health Board apologise to Mr L for the failings identified. She also recommended that the First Health Board carry out an audit of arterial cannula management to ensure nursing staff in the ITU are reviewing arterial cannulas at appropriate intervals and documenting them accurately, and provide evidence that it had done so.