Mr A complained that there had been a delay in diagnosing and treating Mrs A’s, aortic dissection, and that clinicians had failed to communicate with either of them. Mr A also complained about Abertawe Bro Morgannwg University Health Board’s (“the UHB”) response to his letter of complaint.
Having reviewed all of the information, I found that unreasonable delays had occurred. Despite being aware of Mrs A’s medical history, and Mr A’s concerns that she was having a heart attack, Mrs A waited at least 35 minutes before any initial tests were undertaken, including any heart monitoring. Following a further wait Mrs A was examined and referred to a Registrar, where she waited an hour to be seen.
The medical notes suggest that following an examination of Mrs A the clinicians suspected that she had an aortic dissection, although there is no evidence to suggest that this information had been shared with Mr or Mrs A. Due to the serious nature of this illness and the high mortality rate, clinicians would be expected to prioritise the tests to diagnose this condition. However in Mrs A’s case the clinicians failed to do this, instead tests were undertaken to “rule in” other more common disorders rather than “rule out” the aortic dissection. Sadly, Mrs A passed away shortly after being diagnosed.
Finally I found that the UHB had failed to respond to Mr A’s letter of complaint in accordance with its procedure. I also found that there was no evidence that lessons had been learned and that remedies had been put into place to prevent this occurrence again.
I upheld the complaint and recommended that the UHB should apologise and pay the sum of £5000 to Mr A, and Mrs A’s children. I also recommended that relevant staff be reminded of the importance of communication with patients and relatives, and that complaint handlers be reminded of the requirements set out in the UHB’s interim complaints policy and procedures. Finally I recommended that the UHB implement a pathway for treating patients presenting to the SAU with suspected aortic dissection.
A copy of the full report can be downloaded below.