Mrs W complained about the care provided by Aneurin Bevan Health Board (“the Health Board”) to her late husband (“Mr W”) when he was a patient at Nevill Hall Hospital (“the Hospital”) in September and October 2011. Mr W was 80 years old when he died in hospital on 7 October 2011.
Mrs W said that Mr W was deaf, but despite advising staff of this, it was not noted on his records. Mrs W said she believed that her husband was not treated in his best interests and that his care was compromised because staff did not consider his deafness. Mrs W said that she and her husband were not told about a cancer diagnosis by the Hospital. She also said that she was dissatisfied with the way that the Health Board communicated with her and her family both during the time Mr W was a patient and when the Health Board was considering the complaint she made about his care.
The investigation found that, as required by the Equality Act 2010, the Health Board failed to make reasonable adjustments to accommodate
Mr W’s deafness. The investigation also found that the Health Board failed to:
• Record a significant clinical discussion with Mr W about scan results.
• Complete and record appropriate assessments relating to the risk of falling and the use of bed rails.
• Consult Mr W and record his consent for the insertion of a catheter.
• Follow national and local guidance on effective discharge planning.
• Keep appropriate records related to the discharge process.
• Follow relevant guidance on record-keeping.
The Ombudsman upheld the complaint and the Health Board agreed to:
a) give Mrs W an unequivocal written apology for failures identified by this report and make a payment of £500 to reflect the time and trouble taken in pursuing her complaint with the Health Board and this office.
b) formally instruct the nursing and clinical staff involved in Mr W’s case that they must assess patients properly on admission and ensure that all relevant records of such assessments (for example, the Patient Care Record) are completed fully.
c) formally instruct the nursing and clinical staff involved in Mr W’s case to follow the relevant record keeping guidance.
d) formally instruct the clinical staff involved in Mr W’s case to ensure that significant clinical discussions with patients (such as the results of a scan) are recorded properly.
e) formally instruct the nursing staff involved in Mr W’s case to ensure that all appropriate risk assessments are completed and properly recorded.
f) formally instruct the nursing and clinical staff involved in Mr W’s case to follow the relevant discharge planning guidance.
g) share this report with all staff involved in Mr W’s care so that the lessons that should be learned from the report can be understood.
h) ensure that this report is discussed at a meeting of each Directorate that cared for Mr W so that the lessons of the report are disseminated.
i) ensure that this report is discussed at a meeting of the working group responsible for the Health Board’s “Dignified Care?” action plan.
A copy of the full report is available below.