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Ms A through her Assembly Member complained to the Ombudsman that the care her father (“Mr M”) received post-operatively at Ysbyty Glan Clwyd (“the Hospital”) was inadequate, resulting in his death from sepsis. Ms A also complained about the Betsi Cadwaladr University Health Board’s (“the Health Board”) poor handling of her complaint.

The Ombudsman’s investigation found that Mr M had significantly raised CRP levels following surgery. This was a possible indication of a post surgical leak. Mr M’s clinical records showed his CRP levels were tested repeatedly, but were not reviewed. The failure to review Mr M’s increasingly abnormal CRP levels was a fundamental clinical deficiency, resulting in missed opportunities for earlier intervention. The Ombudsman could not rule out the possibility that, had clinicians intervened sooner, a different outcome for Mr M may have resulted. Ms A’s complaint was upheld.

The Ombudsman was critical that it took the Health Board over eight months to reply to Mrs A’s complaint. The reply broadly maintained that Mr M’s treatment was appropriate. Additionally, he had concerns about the rigour and depth of the Health Board’s investigation. He upheld Ms A’s complaint.

The Ombudsman recommended that the Health Board should:

(a) provide a fulsome apology to Ms A both for the significant clinical failings and inadequate investigation of her complaint.

(b) pay Ms A the sum of £8,000 for the distress and uncertainty caused by the failings identified. The Health Board should also provide a further payment of £350 to Ms A in recognition of the shortcomings in complaint handling.

(c) ensure that the guidelines issued by the Association of Coloproctology and the Association of Surgeons are brought to the attention of its medical staff highlighting the importance of recognising that raised CRP levels is a marker that a surgical leak is likely to have occurred.

(d) discuss the contents of the Ombudsman’s report at an appropriate consultant forum and at junior doctors’ teaching sessions.

(e) as part of a wider learning process, the Ombudsman’s report should be shared with the clinical staff within the colorectal team who delivered the care to Mr M.

(f) a copy of the Ombudsman’s report should be shared with the Chair of the Health Board and its Patient Safety and Clinical Governance Group.

A full copy of the report is available below.