Mr and Mrs A complained that the Health Board’s treatment and care of their daughter, Ms B, who had a learning disability (“LD”), fell below a reasonable standard. Specifically, Mr and Mrs A complained that Ms B’s diagnosis and treatment were delayed, that the nursing care she received was not adequate, that her disabilities were not managed appropriately by staff, including an allegation of inappropriate restraint, and that the Health Board’s complaint handling was inadequate.
The investigation found that Ms B’s diagnosis and treatment were delayed, but that this was unlikely to have made any difference to the sad outcome of her death. It partly upheld Mr and Mrs A’s concerns about the nursing care Ms B received and found that Ms B’s disabilities were not managed appropriately by staff, including the handling of Mr and Mrs A’s allegation of inappropriate restraint. Finally, it found that the Health Board’s complaint handling did not reach a reasonable standard, but that it was reasonable for it to ask Mr and Mrs A to confirm their complaint after it was paused for a number of months.
The Ombudsman recommended that the Health Board apologise to Mr and Mrs A for the failings identified by the investigation and repeat its offer to pay Mr and Mrs A £250 to recognise the emotional impact of its delay in handling their complaint. She also recommended that the Health Board introduce a requirement that if any patient is awaiting tests from a specific discipline of medicine, explicit agreement must be obtained before the patient is discharged.
The Ombudsman further recommended that the Health Board Develop a consistent method for logging the admission of all patients with LD to hospital, create a new audit tool, produce and disseminate a discharge toolkit to staff and assign LD Champions to all clinical areas. Additionally, she recommended additional elements to staff training on caring for people who have LD and/or autism and an audit of the LD Health Profile (Passport) and any identified reasonable adjustments.
The Ombudsman recommended that the Health Board record training for staff regarding restrictive practices and that it should make every effort to complete its Safeguarding investigation into the allegation of inappropriate restraint. Finally, she recommended the Health Board resolve identified record keeping issues.