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This complaint is about the shortcomings in the care and treatment provided to
Mr X at Glan Clwyd Hospital. In November 2000 Mr X had his first episode of
bleeding from enlarged blood vessels in the gullet. This is a life-threatening
complication of cirrhosis, a condition in which healthy liver tissue is gradually
replaced with non-functioning scar tissue. The vessels were tied to prevent
further bleeding. Several tests were carried out over the next few months.
They showed clearly that Mr X had cirrhosis. Despite this, he was not
informed of the diagnosis. Nor was he given necessary lifestyle advice. In
September 2001 the hospital apparently made him an outpatient follow-up
appointment, but Mr X was not told about this. This meant that Mr X was
without any medical supervision for several years, with no information about
his condition. As it happens, that probably made little difference to how his
condition developed.

Mr X had further bleeding in August 2008. Again this was treated successfully,
although for a while he was very unwell. This time Mr X received medication
and some, but not all, of the necessary lifestyle advice. The Health Board also
began investigating the cause of Mr X’s cirrhosis, but stopped before finding it.
Not until he requested, and received, a second opinion was Mr X told that he
had been born with cirrhosis.

In 2010 Mr X returned to hospital several times in quick succession. He looked
very unwell. Blood tests showed that his liver was failing. Despite this, the
hospital sent him away, only finally admitting him three days after his
appearance. By then Mr X was in liver failure and had a serious infection.
Mr X rapidly deteriorated and he sadly died, aged 30, seven weeks later.

Had he been treated three days earlier, Mr X should have recovered from the
infection and had a chance of receiving a liver transplant. This opportunity to
survive and flourish was denied to him.

I upheld the complaints that were made to me. The Health Board
subsequently agreed to my recommendations that it write to the family to
acknowledge the failings and provide financial redress to Mr X’s family;
£5,000 in respect of the failings identified in Mr X’s care and treatment plus a
further £500 for the poor complaint handling. The Health Board also agreed
to review the care pathway and its appointments system. The Consultant in
charge of Mr X’s care also agreed to consider the issues raised in the
investigation and learn from these.

A copy of the full report is available below.