Mrs A complained about care and treatment provided to her husband, Mr A, by Cardiff and Vale University Health Board (“the First Health Board”) on behalf of Aneurin Bevan University Health Board (“the Second Health Board”) after he was diagnosed with a brain tumour in 2023.
The investigation specifically considered whether Mr A received adequate post-operative care following neurosurgery at University Hospital Wales (“the First Hospital”), including appropriate monitoring and clinical reviews. The investigation found that Mr A received appropriate post-operative medical care. The nursing care was broadly adequate, but there was a failure to document that his identified needs relating to confusion, agitation and behaviour had been met. This complaint was upheld to that limited extent in relation to the care provided by the First Health Board .
The investigation also considered whether clinicians at the First Hospital took adequate steps to ensure that Mr A’s care was patient led, taking into account his mental capacity to participate in decision-making and involving family members where appropriate. The investigation found that nursing staff failed to demonstrate that they had appropriately considered Mr A’s mental capacity to consent to nursing interventions. There were several missed opportunities to carry out an adequate mental capacity assessment and to engage with Mr A’s family to ensure that his voice was heard and that he received appropriate patient led care. There was also a failure to communicate adequately with Mrs A after she was prevented by illness from visiting the ward. This complaint was also upheld in relation to the care provided by the First Health Board.
The First Health Board agreed to apologise to Mrs A and pay her £750 in recognition of the impact the failings had on Mr A and his family. It also agreed to reinforce learning points relating to nursing documentation with relevant nursing staff and to carry out an audit. This would look at compliance with processes relating to mental capacity assessments and the implementation of deprivation of liberty safeguards (“DoLS”) decisions.