Mrs A complained about a delay in the provision of pain relief for her mother, Mrs C, during her wait in an ambulance outside Glangwili General Hospital on 13 March 2022. She also complained about a delay in carrying out her mother’s surgery to her right hip following her admission on 14 March 2022. Finaly she complained about the delays in reviewing her mother’s moisture sores.
The Health Board, as part of its investigation, had identified that on occasions there was shortcomings in measuring Mrs C’s pain levels. That said, the Ombudsman found the Health Board’s explanation for the delay in administering a nerve block (a medical procedure to help manage pain) procedure was reasonable. However, given the injustice caused to Mrs C regarding her pain management this part of her complaint was upheld. The Health Board was also asked to consider any learning from Mrs C’s case, given the national problem of patients having prolonged waits in ambulances outside of Emergency Departments before being transferred.
We did not uphold Mrs A’s complaint about the delays in carrying out hip surgery as it did not have a longer-term impact on Mrs C’s care or her clinical outcome. We found that Mrs C’s care needs when it came to her personal hygiene skin management were broadly satisfactory. Although the Health Board had identified occasional episodes where Mrs C’s care was not carried out within set timescales, we were satisfied that this did not have an adverse impact on Mrs C. This aspect of Mrs A’s complaint was also not upheld. We invited the Health Board to remind all nursing staff of the need to ensure that skin integrity checks are consistently carried out in a timely manner.
As part of our recommendations the Health Board was asked to apologise to Mrs A for the failing identified in the report and to share this report with its Quality and Patient Safety Committee as part of its quality assurance.