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Mrs W complained about the care and treatment her husband, Mr W, received whilst a patient at Ysbyty Gwynedd (the Hospital). Mr W had been admitted to the Hospital for treatment due to dysphagia (swallowing difficulties) experienced when eating and drinking. He was discharged but was readmitted four days later due to worsening dysphagia. Mrs W complained that there was a very poor standard of care provided to her husband during his admissions which led to deterioration in his condition and, ultimately, contributed to his death.

Mrs W complained about the following:

  •  That a procedure to stretch Mr W’s gullet did not go ahead as planned due to a nursing staff error.
  • That her husband was discharged without having this surgery and once readmitted, due to his declining health, he was too weak to have the procedure carried out.
  • That there was a delay in obtaining a second opinion on her husband’s condition and arranging a transfer to a specialist hospital.

I upheld the majority of Mrs W’s complaints. I found that the clinical care provided to Mr W was inadequate as it was insufficiently intensive and lacked input from his consultant physician. I found that there were a number of clinical failings which contributed to the health problems that emerged during Mr W’s readmission. The most significant of these was the decision to discharge Mr W from the Hospital’s care without carrying out an oesophageal dilatation (a procedure to stretch the gullet) and the delay in raising its concerns regarding Mr W’s deteriorating condition with a specialist hospital. I found that whilst the errors identified were significant, there was no definitive evidence to conclude that the ultimate tragic outcome could have been avoided but for those errors. Finally, I found that in general, the nursing care and management of Mr W was reasonable. However, inadequacies in some of the nursing records prevented a definitive conclusion from being reached in respect of the adequacy of care delivered when the tubing attached to his chest drain became disconnected.

I recommended that the Health Board should reflect on the failings in the care identified and provide confirmation of the further action taken to address the inadequacies in its staff awareness of national guidelines in relation to oesophageal dilatation, the Hospital’s transfer procedures for critically ill patients, the availability of medical cover over Bank Holiday weekend periods and the insertion of chest drains. I recommended that a payment of £500 be provided to Mrs W in recognition of the time and trouble in pursuing her complaint together with a full apology for the shortcomings in the care provided to Mr W and for the Health Board’s failure to recognise these failings sooner.

The full report can be downloaded below.