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Mr Y complained about the care his mother, Mrs X, received from Betsi Cadwaladr University Health Board (“the Health Board”). Mrs X was admitted to hospital in 2015. She was very ill and it had been agreed between staff and the family that she was for supportive care only, i.e. palliative care, to improve comfort and quality of life. Mr Y complained that despite this, Mrs X was twice transferred to a different hospital for a CT scan. On the second occasion, there was no bed available for Mrs X when she arrived. She sadly died on a trolley waiting for a bed. Mr Y also complained about the time taken by the Health Board to provide its complaint response and that the response was sent to the wrong address.

The Ombudsman upheld the complaints about clinical care. In light of the plan for supportive care, a CT scan would not have altered the approach to Mrs X’s care. Despite that, she was twice unnecessarily transferred many miles to another hospital for a CT scan which did not take place. The Health Board’s approach was detrimental to Mrs X’s well-being and the manner of her death. The Ombudsman concluded that Mrs X’s human rights were likely to have been compromised. Her dignity at the end of her life was not respected and she did not have sufficiently considerate care in her final days. The decisions to transfer her for scans which would not have changed the approach to her care failed to take account of her needs as an individual. They failed also to take account of Mrs X and her family’s wider needs as part of family life.

The Ombudsman identified contributory factors including that there was no comprehensive assessment made of Mrs X at her initial admission to A&E, and she was not reviewed by a Consultant for 11 days as no leave cover was in place.

The Ombudsman found that the time taken to investigate and respond to Mr Y’s concern (17 months) was unacceptable. He upheld this complaint, although did not find that the response had been sent to the wrong address.

The Health Board accepted the conclusions of the report and agreed to implement the Ombudsman’s recommendations that it should:

a) Apologise to Mr Y for the shortcomings in Mrs X’s care

b) Provide financial redress to Mr Y of £1,000 in recognition of the distress caused by the failure to provide clear management of Mrs X’s care

c) Provide financial redress of £500 in recognition of the time taken to investigate his complaint

d) Refer the report to the Board, and to the Health Board’s Equalities and Human Rights team to identify how consideration of human rights can be further embedded into clinical practice

e) Remind medical staff on the wards where Mrs X received care of their professional obligations in terms of ethical and clinical management for end of life care in accordance with guidance issued by the General Medical Council

f) Consider the need for clinicians involved in Mrs X’s care to undertake further training in end of life care as part of their continuing professional development

g) Carry out a clinical audit on the wards where Mrs X received care to consider consistency of medical management and decision making

h) Remind medical staff of the requirement to ensure adequate cover arrangements are put in place when taking leave.

A full copy of the report is available below.