Ms A complained about the standard of care provided to her late father, Mr B, while he was an inpatient at Morriston Hospital. Specifically, she said that the lack of medical review or escalation of his care had resulted in his death the following morning. The Ombudsman’s investigation considered the impact of this service failure on Mr B’s condition and whether the outcome for him might have been different had his care been escalated when it should.
Mr B’s high NEWS of 8 indicated a patient who was deteriorating or at significant risk of deterioration. The clinical records indicated that the nursing staff had informed the medical team that afternoon. However, no medical review took place that afternoon or evening and there was no escalation of Mr B’s care. The Ombudsman found that the absence of a medical review for a patient with a high NEWS was a significant failing in care.
It was impossible for the Ombudsman to definitively conclude that the outcome for Mr B would have been different had a medical review taken place. On balance, it was more likely than not that the outcome would have been the same given the nature of Mr B’s condition. However, the Ombudsman accepted that Ms A was left with the uncertainty that without the significant shortcoming in care, there was a slight chance that Mr B may have survived. This uncertainty represented an injustice to Ms A, and the complaint was upheld limited to that extent.
The Ombudsman made several recommendations including that the Health Board should:
• provide a written apology to Ms A for the identified shortcomings
• review its process for escalating deteriorating patients for
medical review and/or critical care and consider whether
any additional action was needed to ensure that this
process was robust.