Report Date

02/08/2024

Case Against

Aneurin Bevan University Health Board

Subject

Clinical treatment outside hospital; GP

Case Reference Number

202207050

Outcome

Not Upheld

Mr R complained about care and treatment provided to his late wife, Mrs R, by Aneurin Bevan University Health Board (“the Health Board”), a GP Practice (“the Practice”) in the area of the Health Board, and Gloucestershire Hospitals NHS Foundation Trust (“the First Trust”). The Public Services Ombudsman for Wales (“the PSOW”) and the Parliamentary and Health Service Ombudsman (“the PHSO”) jointly investigated Mr R’s complaints that there were failures by the above organisations to:

a) Arrange appropriate investigations, treatment and/or referrals after Mrs R was found to have lymphadenopathy (swelling in the lymph nodes which are part of the immune system).

b) Ensure that their clinicians adequately communicated and coordinated with other clinicians involved in Mrs R’s care.

The investigation also considered the complaints that the Health Board failed to:

c) Provide adequate care and treatment to manage Mrs R’s sepsis or risk of sepsis (when the body overreacts to an infection and damages the organs and tissue).

d) Inform Mrs R’s family about her deterioration in time to enable a visit before she died.

Complaint a) was not upheld in relation to the Practice and the Health Board. The investigation found that the First Trust’s investigation of Mrs R’s lymphadenopathy was unduly delayed. As a result, an opportunity was missed to arrange a biopsy which would have provided Mrs R with greater certainty about what was causing the deterioration of her health. Complaint a) was upheld in relation to the First Trust.

The investigation found that while there were shortcomings in the way the Practice coordinated Mrs R’s care, it faced a difficult task because of the number of organisations involved and its lack of access to electronic patient information about care provided in England. Similarly, while the Health Board could have improved the way it communicated with its counterparts in England, its actions did not fall below the expected standards. Complaint b) was not upheld in relation to the Practice and the Health Board. The investigation found that there were a series of significant communication failings by the First Trust which resulted in missed opportunities to improve the coordination of Mrs R’s care and avoid the confusion that arose about the status of clinical investigations by different health bodies. Complaint b) was upheld in relation to the First Trust.

The investigation found that the care provided to Mrs R by the Health Board after she was admitted to hospital with suspected sepsis fell outside the range of acceptable practice. As a result, there was a missed opportunity to take steps to minimise her discomfort and suffering in the last hours of her life. Complaint c) was upheld. The investigation also found that there was a delay in recognising that Mrs R was deteriorating rapidly. This deprived Mr R of a better likelihood of seeing his wife before she died. Complaint d) was upheld.

The Health Board agreed to recommendations including to apologise to Mr R, consider the report at a relevant clinical governance meeting and review its Deteriorating Patients Policy. The First Trust agreed to recommendations including to apologise to Mr R, consider the report at a relevant clinical governance meeting and take actions to address factors identified as contributing to delays in Mrs R’s clinical pathway.

The investigation identified that due to the Practice’s lack of access to English IT systems, it did not have the same level of access to information about the care provided to Mrs R in England as it had in relation to the care provided in Wales. The PSOW and the PHSO were concerned that this issue had the potential to compromise the quality of care provided to other patients at GP practices along the border in Wales (and possibly also in England). The PSOW and the PHSO wrote jointly to the respective health ministers for the UK and Welsh governments asking them to liaise with relevant stakeholders to address the concerns raised.