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Mrs T complained about the treatment her husband, Mr T, received in hospital. She complained that he received excess intravenous fluids and that this fluid overload caused subsequent health problems, including multiple strokes, from which he sadly died in May 2011. Mrs T also complained that errors were made in her husband’s medication when admitted to hospital, that the diagnosis of his stroke was delayed and that had he received appropriate and timelier treatment, he may have survived.

The Ombudsman found that the instance of fluid overload was not clinically significant in terms of the sad outcome. However, the Ombudsman upheld Mrs T’s complaint, finding that the Health Board had failed to act in accordance with national guidelines for the treatment of stroke. The Ombudsman concluded that errors were made with Mr T’s regular medication and that opportunities to diagnose Mr T’s stroke and to implement treatment which may have increased his chances of survival were missed.

The Ombudsman recommended that the Health Board should:

1. Issue to Mrs T and her family a comprehensive apology for the failings identified in this report.

2. Review its arrangements in respect of post-admission medication reconciliation and ensure that a systematic medicine reconciliation programme is in place.

3. Ensure that staff training in respect of recognising acute stroke is up to date, with particular reference to the 2012 Stroke Guidelines issued by the Royal College of Physicians.

4. Ensure that use of the Rosier score system (or a similarly recognised tool), in order to identify patients who are likely to have had an acute stroke, is implemented.

5. With particular reference to the current Stroke Guidelines and NICE guidance, review its arrangements for the identification and treatment of acute stroke and consider including the following measures:

a) All patients who may have had an acute stroke (i.e. have been assessed as having a positive Rosier score) should be immediately assessed by a physician trained in stroke medicine to determine whether thrombolysis is suitable;

b) Suitable patients should have immediate CT scanning and, in all cases, within one hour.

c) All patients who may have had an acute stroke should be admitted immediately to a specialist acute stroke unit.

d) All patients who may have had an acute stroke should have a swallowing screening test, using a validated tool, by a trained professional within four hours.

6. Review the findings set out in its various complaint responses to Mrs T and to this office and take action to ensure that its own complaints investigations are in accordance with the Putting Things Right scheme, are sufficiently robust, demonstrably independent and, where appropriate, critical of identifiably poor care, which should include the introduction of a quality assurance audit of a sample of its completed complaint investigations.

7. Issue to Mrs T a cheque in the sum of £5000 in respect of the time and trouble to which she has been put in pursuing this complaint and in recognition of the additional distress caused to her and her family as a result of the uncertainty with which they now live over whether Mr T might have survived the initial stroke.

A copy of the full report is available below.