Clinical treatment in hospital
Upheld in whole or in part
Non-public interest report issued: complaint upheld
Hywel Dda University Health Board
Ms B complained about the clinical care and treatment provided by Hywel Dda University Health Board to her late father, Mr A, from 1-20 December 2021. The investigation considered whether it was appropriate that Mr A did not receive a CT scan (the use of X-rays and a computer to create an image of the inside of the body) during the initial days of admission to establish the extent of damage to his lungs, and whether more could have been done to prevent and treat the hospital acquired klebsiella infection contracted by Mr A. It also considered whether Mr A made a fully informed decision regarding being placed in an induced coma.
The Ombudsman found that the decision not to carry out a CT scan, and provision of alternative precautionary treatment instead, was clinically appropriate as per guidance at the time. The Ombudsman also found that the clinical care Mr A received, both prior to and after the identification of the klebsiella infection, was reasonable in terms of the standards expected. There was no clear indication that the infection itself was a contributing factor in his death. These aspects of Ms B’s complaint were not upheld. The Ombudsman found that the decision to place Mr A in an induced coma was medically appropriate. However, due to a lack of documented discussion, it could not be concluded that Mr A made an informed decision to proceed, or that his consent was properly obtained. This complaint was upheld.
The Ombudsman recommended that the Health Board apologise for the failings identified around discussion and consent to the induced coma, and to remind staff of the importance of properly documenting such discussions and patient consent where practical. She also recommended that the Health Board offer a financial redress payment of £1000 for the injustice caused by the failings.