Miss C complained on behalf of her late father, Mr A, about the care and treatment he received from Swansea Bay University Health Board (“the Health Board”) when he was admitted to hospital between 1 November and 9 December 2022.
Specifically, the investigation considered whether the care and treatment provided to Mr A was clinically appropriate, given the diagnosis of a traumatic intracranial haemorrhage (bleeding within the skull due to a head injury), and whether the nutritional support provided to Mr A was also clinically appropriate.
The investigation found that, overall, the fundamental clinical management of Mr A was appropriate. However, there were flaws in anticoagulation management protocols and in the implementation of his Do Not Attempt Cardiopulmonary Resuscitation (“DNACPR”) order. Despite this, these failings did not contribute to Mr A’s death. This part of the complaint was not upheld.
However, the nutritional screening of Mr A was found to be below the required standard. The screening was found to be often inaccurate due to his weight not being taken and the recording and recognition of his poor dietary intake. In addition, there was a missed opportunity to refer Mr A to a dietitian at an earlier stage. This was an injustice to Mr A as his nutritional needs were not adequately met in the latter stages of his life. This part of the complaint was upheld.
The Ombudsman recommended the Health Board apologise to Miss C, share the report with the nursing team involved in Mr A’s care, review its protocol for referrals to a dietitian and review its protocol around mental capacity assessments.
The Health Board agreed to implement the recommendations within the specified timeframes.