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Ms C complained about the care her father, Mr D, received when he was admitted to Ysbyty Gwynedd. Ms C complained that Mr D’s cause of death had not been accurately recorded. Ms C also complained about the way her complaint was handled and the length of time taken to provide her with a response.

The Ombudsman found that the care and treatment provided to Mr D was not of a reasonable standard. The Health Board did not adequately monitor Mr D’s condition and missed a number of opportunities to escalate his care. Had Mr D’s care been appropriately escalated his death may have been avoided.

The Ombudsman found that the form submitted to the Coroner by the Health Board did not accurately reflect the cause of Mr D’s death.

The Ombudsman also found that the complaint was poorly handled, the amount of time taken to deal with the complaint was unreasonable and the final response did not contain the Serious Incident Report the Health Board had said it would provide.

The Ombudsman upheld the complaint and recommended that the Health Board:

a) Undertake a NEWS (National Early Warning Score) audit. This should include a minimum 10% dip sample of the NEWS recorded on the ward in the past three months. If members of staff involved in the recording of NEWS for Mr D are now working in a different area, the audit should also include a sample of their current practice. If anomalies are identified, an action plan should be prepared to put this right.

b) Share this report with the nursing staff involved in this case. Those members of staff should be given training on NEWS and escalation procedures.

c) Ensure that there is a robust handover system in place and that all acutely ill patients undergo a daily review by a registrar (or above), including on weekends and holidays.
Public Services Ombudsman for Wales: Investigation Report

d) Share this report with the doctors involved in this case. The doctors should then review the report and medical notes with their appraiser to identify areas where practice could be improved.

e) Discuss this case with the Coroner and based on that discussion undertake an audit (minimum 10% dip sample) of coroner referral forms for the past three months. If inconsistencies or inaccuracies are identified, an action plan should be prepared to address them, this may include introducing a review system or additional training for doctors preparing the forms.

f) The Head of Corporate Governance should review the complaint handling in this case. The review should seek to identify what happened to the Serious Incident Report.

g) Apologise to Ms C and her family for the failings identified in this report. A meeting with the Chief Executive or the Medical and Nursing Director should be offered to Ms C.

h) Make a payment to Ms C of £10,000 in recognition of the distress and uncertainty caused by the clinical failings identified in this report. This payment is also in recognition of the time and trouble taken in pursuing this complaint, due to the complaint handling failings identified in this report.