Mrs A complained about the care provided for her late father, Mr B, by Abertawe Bro Morgannwg University Health Board (“the Health Board”), at Morriston Hospital (“the Hospital”). Her complaint concerned the diagnosis and investigation of his condition, his treatment in the Emergency Department, his discharge from the Hospital, his spinal surgery, his ophthalmology input, his manual handling assessment and his personal care. Mr B had cancer.
The Acting Ombudsman upheld Mrs A’s complaint. She considered that the Health Board had not investigated Mr B’s condition appropriately, diagnosed it correctly soon enough, provided timely triage for him, managed his discharge, pain and handling-related needs effectively, or consistently given him a reasonable standard of personal care. She recommended that the Health Board should:
(a) Apology – Write to Mrs A to apologise for the failings identified.
(b) Financial redress – Pay Mrs A a nominal sum of £1500 in recognition of the significant distress that its failings caused.
(c) Red Flags – Formally remind its clinicians of the importance of identifying and responding to Red Flags.
(d) Triage arrangements – Satisfy itself that its triage arrangements should avert any delay akin to that experienced by Mr B.
(e) Pain policy – Review its pain policy to ensure that it complies with the relevant pain management guideline.
(f) Discharge-related training – Arrange and provide discharge-related training for its nursing staff members.
(g) Patient handling – Formally remind its nursing staff members that they must ensure that their patient handling complies with the relevant best practice guidance.
(h) Personal care – Formally remind its nursing staff members that they must assess and review the personal care needs of their patients systematically and record the service provision associated with them consistently.
(i) Catheter care – Formally remind its nursing staff members that they must ensure that their catheter care complies with the relevant best practice guidance.
(j) Pain management training – Arrange and provide pain management training for its nursing staff members.
(k) Report sharing – Share her investigation report with all relevant staff members and discuss it in an appropriate forum.
The Health Board agreed to comply with these recommendations.
A copy of the full report is available below.