Select Your Language

Mrs Q complained about the care and treatment her mother, Mrs F, received whilst a patient at Ystrad Mynach Hospital (the hospital). Mrs F had been admitted to the hospital for assessment due to a deterioration in her mental health. Mrs Q complained that her mother received a very poor standard of care during her admission which led to a more rapid deterioration in her mental and physical condition and ultimately, contributed to her death.

Mrs Q complained about the following:

That the family’s requests for medical intervention and a transfer to a medical ward were ignored despite signs of Deep Vein Thrombosis (DVT) and deterioration in her condition during the weekend of her passing away.

That the standards of personal care provided to Mrs F were poor and that Mrs F lost considerable weight during her admission to the hospital.

That the communication with her and Mrs F’s family and the information provided about her care plan were grossly inadequate.

I upheld the majority of Mrs Q’s complaints. I found that the hospital’s procedures for the earlier detection of DVT in a patient displaying potential symptoms were lacking. I also found that the staff failed to act in an appropriate manner and contact a doctor for a medical opinion following a deterioration in Mrs F’s condition. The hospital also failed to seek or provide adequate reasons why access to a doctor over the weekend period was not available. I found that in general, the overall record keeping for the period of Mrs F’s admission was extremely poor. This had led to inadequacies in the response provided to the family during the internal complaints process and also in the proposed Action Plan implemented by Aneurin Bevan Health Board (the Health Board) to address the family’s concerns. Finally, I found that the standard of care and treatment provided to Mrs F during her admission fell below a reasonable standard. There was no evidence that Mrs F’s personal hygiene or nutritional needs were being met or that the care plans were implemented.

I recommended that the Health Board should reflect on the failings identified and provide confirmation of the further action taken to address the inadequacies in the hospital’s procedures and operational policies, to improve its staff awareness of DVT and to ensure that early detection is promoted, to ensure that its staff recognise deterioration in a patient’s condition, to provide adequate medical cover support to its nursing staff and a clear pathway for referral of patients with medical needs and also to review the availability of medical cover on the ward including out of hours and weekend cover. I also recommended that an apology be provided for the shortcomings in the care provided to Mrs F and for its failure to act more promptly in light of the family’s concerns.

The full report can be downloaded below.