Mrs A and Mr B complained about the Abertawe Bro Morgannwg University Health Board (“the UHB”) in relation to the care provided to their brother Paul in hospital during late 2008/early 2009. They explained that Paul had severe learning disabilities. He had been admitted to hospital for a serious bowel problem. Surgeons operated on Paul soon after his admittance. Paul sadly died in hospital about three weeks later due to respiratory problems involving excess secretions in his bronchial airways.
Mrs A and Mr B complained about many aspects of Paul’s nursing and clinical care. They provided papers which showed that the nursing care had been strongly criticised in a Protection of Vulnerable Adults (“POVA”) investigation run by the former NHS Trust. However, they remained unconvinced that the resulting action plan was adequate. Moreover, they considered that the investigation had not focussed on clinical care. Their main clinical concerns were that Paul had contracted pneumonia whilst in the Intensive Therapy Unit (“ITU”), been transferred prematurely to a general ward (“the Ward”) and that his care on the Ward in the days leading to his tragic death was poor.
The Ombudsman’s investigation did not focus on nursing care, as the POVA process had been thorough in that regard. However, he found that Paul’s nursing care on the Ward had been very poor and when combined with his clinical care, had produced an unacceptable level of treatment. With regard to Paul’s clinical care, he did not agree with every aspect of Mrs A and Mr B’s complaint. However, he concluded that the clinical care was generally well below a reasonable standard. In the investigation, he found that that there was:
• a lack of outreach support to the Ward from the ITU
• an over reliance on the assumption that Paul’s symptoms were psychological rather than clinical
• a lack of involvement of the consultant in charge of Paul’s care
• a failure to supervise junior doctors
• inadequate examinations of Paul
• failure to ensure that vital suctioning care was provided
• an inability among doctors to notice that nurses were not recording Paul’s observations properly.
The Ombudsman also concluded that the hospital had failed to comply with the provisions of the Disability Discrimination Act regarding Paul, primarily by not making reasonable adjustments to its service to cater for his special needs.
The Ombudsman strongly upheld the main aspect of the complaint, concerning Paul’s clinical care. Finally, he stated that his view was that reasonable nursing and clinical care might have altered the outcome for Paul, although this was uncertain.
The Ombudsman made a number of recommendations. These included a payment of £1500 to both Mrs A and Mr B for the uncertainty that they have to endure over whether Paul may have survived with adequate care. He recommended learning disability awareness training for staff; many reminders for staff about appropriate care and relevant audits and inspections. The Ombudsman also recommended that the matter be discussed at a full meeting of the UHB with regard to how it can best ensure that it complies with the Equality Act. The UHB agreed to implement his recommendations.
A copy of the full report can be downloaded below.