Mr D complained about the care and treatment that his late mother, Mrs M, received at Glan Clwyd Hospital and Llandudno General Hospital. He complained that:
1. Clinicians failed to adequately investigate and appropriately treat Mrs M’s symptoms of abdominal pain, gastro-intestinal upset and weight loss which she developed following bowel surgery.
2. Clinicians failed to accurately assess Mrs M’s frail condition and discharged her without appropriate home care support in place. This was subsequently provided by the Council but was inadequate and, within days, Mrs M was readmitted to hospital.
3. The decision to remove Mrs M’s nasogastric tube led to further weight-loss and deterioration.
4. A secondary cause of Mrs M’s death – an ischaemic bowel – was not identified from scans or investigations conducted during her admissions.
5. The Health Board and the Council failed to coordinate their response to the complaint. The Council’s response was received 6 months after the response provided by the Health Board.
The Ombudsman upheld complaint 1. He found that senior physicians at both hospitals (including the Colorectal MDT) failed to identify that Mrs M had developed a post-operative blockage in the small bowel (a small bowel obstruction – SBO). He found that, despite conspicuous radiological and clinical evidence pointing to this, physicians inappropriately excluded a physical cause for Mrs M’s symptoms and attributed her weight loss and aversion to eating to a “food phobia”. The Ombudsman could not definitively conclude that the failure to identify and treat the SBO meant that Mrs M’s death was preventable. This was because it was unclear whether she could have sustained further surgery, given her frail condition and comorbidities. The Ombudsman nevertheless considered this to be an alarming, systemic misdiagnosis and considered the uncertainty surrounding whether an opportunity to surgically intervene was lost to be, in itself, an injustice to Mrs M and her family.
The Ombudsman upheld complaint 2. He found that the attempt to discharge Mrs M failed due to multiple shortcomings on the part of both the Health Board and the Council in relation to pre-discharge planning and to the post-discharge support Mrs M received.
The Ombudsman did not uphold complaint 3. He found that the nasogastric tube was appropriately managed and was removed at Mrs M’s request.
The Ombudsman upheld complaint 4. He found that, although difficult to detect, ischaemia might have been preventable had the clinical suspicion of an SBO been considered and pursued. However, the Ombudsman could not definitively conclude this because direct treatment of ischaemia would have rested on Mrs M being able to sustain surgery. As with complaint 1, the Ombudsman nevertheless considered that the uncertainty surrounding the question of whether an opportunity to conduct surgery was lost, amounted, in its own right, to a serious injustice to the family.
The Ombudsman upheld complaint 5. He found that there were complaint-handing failings on the part of both bodies.
The Ombudsman recommended that:
The Ombudsman additionally recommended that the Health Board:
Both the Health Board and the Council accepted the findings and conclusions of the report and agreed to implement these recommendations.