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Mr O had a diagnosis of dementia. He was admitted to Cefn Coed hospital in 2009 and remained there until his death four months later. His daughter, Miss O, complained about aspects of his care towards the end of his life.

Mr O was assessed as ‘at risk’ of developing a pressure sore. Despite this, he was not re-assessed until after he developed significant pressure sore two months later. Had assessment and further preventive measures been taken, it is possible that the pressure sore might not have happened.

There was a lack of nutritional assessment, and Mr O was not referred to a dietician. Further, he should have been referred to a Speech & Language Therapist for a swallow assessment. Without regular nutritional assessments and without the input of a dietician and SALT, it is reasonable to conclude that the provision of food and fluid to Mr O was not as good as it could have been.

No end of life care pathway was in place at the time of Mr O’s death, and his end of life care did not comply with the principles of palliative care. Nor was his pain management reasonable or consistent with guidelines. It therefore seemed likely that his pain management was insufficient on occasions.

My investigation identified patterns of failures to assess (pressure care, nutrition), to refer (to SALT, to a dietician, to palliative care), and to plan (end of life care). My office has issued two other reports to the Health Board this year both of which concerned elderly patients and in which some similar failings were identified, albeit at a different hospital and where the events occurred in 2008 and 2011. For that reason, I have referred this report to Healthcare Inspectorate Wales for it to take into account in planning its future inspections.

I made a range of recommendations to the Health Board to prevent similar failings happening again. I also recommended that the Health Board apologise to Miss O and her family, and pay her £2000 for the distress exacerbated by failures in care during her father’s last weeks of life. The Health Board agreed to implement all my recommendations.

A copy of the full report can be downloaded below.