Clinical treatment in hospital
Upheld in whole or in part
Non-public interest report issued: complaint upheld
Swansea Bay University Health Board
Mr B complained that the Health Board failed to provide his partner, Mr C, with appropriate care and treatment. In particular, Mr B complained that there were delays in the Health Board undertaking tests and investigations and that the Health Board failed to appropriately communicate with Mr C and his family. Mr B also complained that the different clinicians involved in Mr C’s care failed to appropriately communicate with each other.
The Ombudsman’s investigation found that the Health Board carried out appropriate tests and investigations. He found that as Mr C needed an operation that was high-risk, it was appropriate for the Health Board to refer Mr C for further tests and investigations. Therefore, the Ombudsman did not uphold this element of Mr B’s complaint.
The Ombudsman’s investigation found that there was a significant delay in Mr C receiving the operation that he required. He found that this was a service failure which caused a significant injustice to Mr C because he suffered very debilitating symptoms for a longer period than necessary. Therefore, the Ombudsman upheld this element of Mr B’s complaint.
With regard to the communication between the different clinicians, the investigation found that there was, at times, a failure on the part of the clinicians to interpret communications from other clinicians appropriately. The Ombudsman found that a specific meeting should have been set up involving all of the clinicians involved in Mr C’s care. Therefore, he upheld this element of Mr C’s complaint to a limited extent.
The Ombudsman also found that there were limited failings in the communication with Mr C and his family. Clinic letters and communications between the different clinicians involved in Mr C’s care were not copied to Mr C.
The Ombudsman found that there should have been a lead clinician to communicate with Mr C and his partner. Therefore, the Ombudsman upheld this element of Mr B’s complaint.
The Ombudsman recommended that the Health Board:
a) Apologises to Mr C and Mr B for the failings identified in this report.
b) Provides Mr C with a redress payment of £750 in recognition of the distress these failings gave rise to.
c) Reviews whether a lead clinician should be appointed to communicate with Mr C and Mr B. The outcome of this review should be communicated to the Ombudsman.
d) Shares this report with the relevant cardiology and cardiothoracic clinicians and confirms to the Ombudsman that the report has been used for critical reflection and learning.